Chapter 20: Alteration in Bowel Elimination/Gastrointestinal Disorder
The nurse is talking with a woman in her second trimester of pregnancy who has been diagnosed with polyhydramnios. The physician has ordered an ultrasound be performed to check for the presence of esophageal atresia. Which statement by the woman indicates an understanding of the relationship between these conditions? "Enzymes in amniotic fluid can cause the development of esophageal atresia." "Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup." "Reductions in amniotic fluid are associated with the development of esophageal atresia." "Babies with esophageal atresia produce an excessive amount of amniotic fluid."
"Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup."
A 4-month-old has had a fever, vomiting, and loose watery stools every few hours for 2 days. The mother calls the physician's office and asks the nurse what she should do. Which response by the nurse is most appropriate? "Give a clear pediatric electrolyte replacement for the next few hours, then call back to report on how your child is doing." "Continue breastfeeding as you have been doing. The fluid from the breast milk is important to maintain fluid balance." "Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment." "Do not give the child anything to drink for 4 hours. If the fever goes down and the loose stools stop, you can resume breastfeeding."
"Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment."
The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. What is the most important instruction to emphasize to the mother to avoid an emergency situation? "Call the doctor immediately if the stoma is not pink/red and moist." "Gather all of your supplies before you begin." "You must be meticulous in caring for the surrounding skin." "You may need adhesive remover to ease pouch removal."
"Call the doctor immediately if the stoma is not pink/red and moist."
The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply. "The entire family will need to eat a gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats." "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "Most children with celiac disease are diagnosed within the first year of life." "The only treatment for celiac disease is a strict gluten-free diet."
"Gluten is found in most wheat products, rye, barley and possibly oats." "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet."
The nurse is assessing a toddler and palpates a sausage-shaped mass in the upper mid abdomen. When taking the toddler's history, what question would the nurse ask the parent first? "Can you describe any pain your toddler is having?" "Has your toddler been having different colored stools?" "How is your toddler's appetite?" "Has your toddler been around anyone who has been sick?"
"Has your toddler been having different colored stools?"
The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which response from the mother indicates a need for further teaching? "My son could have some appearance-related self-esteem issues." "An incarcerated hernia is rare, but it can occur." "I can tape a quarter over the hernia to reduce it." "I need to watch for pain, tenderness, or redness."
"I can tape a quarter over the hernia to reduce it."
The adolescent has been diagnosed with gastroesophageal reflux disease (GERD). Which statement(s) by the adolescent indicates that adequate learning has occurred? Select all that apply. "It sounds like the health care provider is reluctant to give me bisacodyl because of the side effects." "The famotidine may make me confused." "I will probably need a laxative because of the omeprazole." "I should try to lie down right after I eat." "The omeprazole could give me a headache."
"It sounds like the health care provider is reluctant to give me bisacodyl because of the side effects." "The famotidine may make me confused." "The omeprazole could give me a headache."
The nurse is caring for a child with gastrointestinal concerns. What statement by the parent would indicate a need for the nurse to further assess the child for constipation? "My child does not have liquid stool or leak liquid stools that I am aware of." "My child only has a bowel movement about four times a week." "My child has such large bowl movements that it clogs the toilet." "My child eats vegetables and fresh fruit, but does not like beans."
"My child has such large bowl movements that it clogs the toilet."
The nurse is caring for a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate? "Encourage him to have some soda." "Offer him some orange juice." "Try some Anbesol or Kank-A." "Offer 'magic mouthwash' followed by a popsicle."
"Offer 'magic mouthwash' followed by a popsicle."
The nurse is caring for an infant. The infant's mother asks the nurse, "What did the doctor mean when he said she may have regurgitation?" What response by the nurse is appropriate? "Regurgitation is not normal in infants. She will need more testing to see what is causing this." "Regurgitation is the backflow of stomach contents up into the esophagus or mouth." "Regurgitation is just another term for vomiting. All infants vomit some." "Regurgitation is when an infant can't tolerate their formula. You will need to switch."
"Regurgitation is the backflow of stomach contents up into the esophagus or mouth."
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac disease. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac disease? "She loves hot dogs, and we always cut hers up into small pieces." "The soup we eat at our house is all made from scratch." "I have learned to make my own bread with no gluten." "Even though milk and pudding are good for her, we don't give her those foods."
"She loves hot dogs, and we always cut hers up into small pieces."
The nurse is caring for a child following surgery due to a motor vehicle accident. The child suffered extensive damage to the small intestine resulting in short bowel syndrome. The parents voice concern to the nurse that their child will "never be the same." Which is the best response by the nurse? "I cannot imagine what you are going through. We are here to support and educate you on your child's condition and treatments." "There are so many new treatments available every day. There may be something to correct this in the near future." "I know it must be difficult for you to wrap your heads around this situation but there was nothing you could have done to prevent this from happening." "Having a chronic condition is difficult but you have to be strong for your child. You are your child's main support and will be needed."
"I cannot imagine what you are going through. We are here to support and educate you on your child's condition and treatments."
The nurse has performed client education for a 15-year-old boy with Crohn disease and his parents regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning has occurred? "I have to be careful because I am prone to not absorbing nutrients." "I may end up with a colectomy because the disease is continuous from the beginning to the end of my intestines." "I have a lot of diarrhea every day because of how my small intestine is damaged." "It's unusual for someone my age to get Crohn disease."
"I have to be careful because I am prone to not absorbing nutrients."
The nurse is caring for a child with celiac disease. The parents and the child have attended a class with a group of other clients with the disorder. Which statements by the child or the parents indicates the need for further teaching? Select all that apply. "I love pasta, so as long as I only eat it occasionally I should be fine." "I hope they find a cure for celiac disease someday." "Celiac disease is the same as gluten intolerance that everyone is talking about these days." "I must be careful to eat only 100% whole grain foods." "My brother and sister are more likely to develop celiac disease since I have it."
"I love pasta, so as long as I only eat it occasionally I should be fine." "Celiac disease is the same as gluten intolerance that everyone is talking about these days." "I must be careful to eat only 100% whole grain foods."
A nurse caring for an infant born with a cleft palate notices that the parents rarely interact with their child. The nurse overhears the mother telling her spouse that she "feels like crying" every time she looks at their infant. What would be the best response from the nurse? "Keep in mind that your infant's condition is not life-threatening and can be corrected eventually." "Many infants are born with this condition. Your infant's palate is not nearly as bad as some cases." "Your infant needs you right now. You should put your negative feelings about the condition aside for your infant's sake." "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?"
"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?"
The nurse is caring for an infant recently diagnosed with oral candidiasis (thrush) who has been prescribed nystatin. Which statement by the infant's mother would suggest a need for further education? "I will watch for diaper rash." "I will make sure to clean all of her toys before I give them to her." "I will add the nystatin to her bottle four times per day." "I will use a cotton tipped applicator to apply the medication to her mouth."
"I will add the nystatin to her bottle four times per day."
The student nurse is caring for a child with the nursing diagnosis "Risk for fluid volume deficit related to inadequate oral intake." Which statement by the student would indicate a need for further education by the nursing instructor? "I will monitor her IV line to help maintain her fluid volume." "I will teach her mother to give her small drinks frequently." "I will weigh her every morning at the same time." "I will make sure there is plenty of orange juice available. It's her favorite juice."
"I will make sure there is plenty of orange juice available. It's her favorite juice."
The nurse is performing discharge teaching for an adolescent diagnosed with peptic ulcer disease. Which statement(s) by the adolescent demonstrates learning has occurred? Select all that apply. "I can eat whatever I want to as long as I take my medications." "I can use ibuprofen for pain." "My proton pump inhibitor should be taken when I feel discomfort." "I will need to make sure to take all of the antibiotic prescribed." "I will be starting yoga soon to help with the stress."
"I will need to make sure to take all of the antibiotic prescribed." "I will be starting yoga soon to help with the stress."
The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? "What foods has your child eaten during the last few days?" "Tell me about the types of stools your child has been having." "How many times a day does your child urinate?" "How long has your child been toilet trained?"
"Tell me about the types of stools your child has been having."
The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis? "Your child will receive counseling so the underlying concerns will be addressed." "We will give enemas until clear and then teach you how to do these at home." "The treatment for the disorder will be a surgical procedure." "Your child will be treated with oral iron preparations to correct the anemia."
"The treatment for the disorder will be a surgical procedure."
The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate? "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." "The health care provider will remove about half of the herniated contents during the procedure." "If you do not understand this, I need to cancel your surgery and have the health care provider come back." "All this means is that the herniated intestines are twisted and edematous, which is why you need surgery."
"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery."
The nurse is caring for a newborn diagnosed with imperforate anus following delivery. The physician has discussed the treatment options and prognosis with the parents. The nurse is talking with the parents and determines that learning has occurred when the parents make which statement? "We aren't sure if our baby will need surgery at some point for this problem." "Since our baby has a defect high in the anorectal opening there is a good chance that stool continence won't be a problem." "We know we will need to use baby wipes around the anal area after surgery to prevent infection." "We are worried that our child may have other congenital problems that we aren't aware of."
"We are worried that our child may have other congenital problems that we aren't aware of."
A child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful? "We should not stop this medication abruptly." "She might lose some weight initially." "We might notice some of the medication in her stool." "This drug helps to control the abdominal cramping."
"We should not stop this medication abruptly."
The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires about the testing required to evaluate the condition. How should the nurse respond? "You will most likely have viral studies." "You will most likely have an ultrasound evaluation." "You will most likely have a blood test to check for certain antibodies." "You will most likely be tested for ammonia levels."
"You will most likely have a blood test to check for certain antibodies."
Which client most likely has ulcerative colitis rather than Crohn disease? 12-year-old with oral temperature of 101.6° F (38.7° C) 14-year-old female with full-thickness chronic inflammation of the intestinal mucosa 18-year-old male with abdominal pain 16-year-old female with continuous distribution of disease in the colon, distal to proximal
16-year-old female with continuous distribution of disease in the colon, distal to proximal
The nurse is providing care to a child who has had an appendectomy for a perforated appendix. The nurse would anticipate intravenous antibiotic therapy for how long? 5 to 7 days 1 to 3 days 7 to 14 days 3 to 5 days
7 to 14 days
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of congenital aganglionic megacolon? There are recurrent paroxysmal bouts of abdominal pain. A partial or complete intestinal obstruction occurs. In this disorder the sphincter that leads into the stomach is relaxed. A thickened, elongated muscle causes an obstruction at the end of the stomach.
A partial or complete intestinal obstruction occurs.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurately related to the diagnosis of pyloric stenosis? A partial or complete intestinal obstruction occurs. In this disorder the sphincter that leads into the stomach is relaxed. A thickened, elongated muscle causes an obstruction at the end of the stomach. There are recurrent paroxysmal bouts of abdominal pain.
A thickened, elongated muscle causes an obstruction at the end of the stomach.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family? Explain to the parents that surgical intervention will fix the defect in the baby's lip. Ask the parents if they have any questions regarding the care of their child. Refer the family to a social worker or mental health practitioner. Teach the mother the appropriate technique for breastfeeding an infant with cleft lip.
Ask the parents if they have any questions regarding the care of their child.
The nurse is caring for a pediatric client with idiopathic celiac disease. Which meal will the nurse select for this client? Whole wheat pasta, meatballs, carrot sticks, apple, and water Meatloaf, green beans, peanut butter cookie, and fat-free milk Baked salmon, potato slices, vanilla ice cream, and apple juice Ham and cheese sandwich, orange slices, chips, and whole milk
Baked salmon, potato slices, vanilla ice cream, and apple juice
A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition? Upper endoscopy Endoscopic retrograde cholangiopancreatography Surgery Barium enema
Barium enema
The nurse is taking a health history of a 2-year-old girl presenting with a sudden onset of severe vomiting. Which description would suggest an obstruction? Bilious vomiting Projectile vomiting Effortless vomiting Bloody vomiting
Bilious vomiting
The nurse is administering an enteral feeding to a child with a gastrostomy tube (G-tube). Which action will the nurse take when administering a prescribed feeding through the client's G-tube? Check for gastric residual before starting feeding. Use a syringe plunger to administer the feeding. Position the client with the head of the bed at a 20° angle. After feeding, flush the tube with a small amount of saline and leave the G-tube open for 2 minutes.
Check for gastric residual before starting feeding.
A child presents with intermittent abdominal pain, severe anorexia, and diarrhea. The child's height and weight are significantly behind standards for age. There is skin breakdown in the anal region. The nurse explains that this presentation is consistent with which diagnosis? food poisoning Crohn disease ulcerative colitis Hirschsprung disease
Crohn disease
The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child? Forceful vomiting followed by the child being eager to eat again Severe constipation with occasional ribbon-like stools Effortless vomiting just after the child has eaten Bouts of diarrhea with failure to gain weight
Effortless vomiting just after the child has eaten
A preschool-aged child has celiac disease. The parent is preparing a gluten-free diet. The nurse knows that the parent understands the diet when the parent prepares which breakfast foods? Eggs and orange juice Cheerios (oat cereal) and skim milk Rye toast and peanut butter Wheat toast and grape jelly
Eggs and orange juice
The mother of a newborn with a cleft lip reports she is having a hard time looking her baby. What is the best action by the nurse? Encourage the child's mother to hold her infant against her shoulder to provide closeness while not looking at the defect. Tell the mother that while this is difficult it will get easier. Encourage the mother to provide care for her infant. Explain that surgery will make this better in the future.
Encourage the mother to provide care for her infant.
A parent brings a 2-year-old child to the health clinic with reports of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and his child is enrolled in a local day care center. Based on this information, what gastrointestinal condition might the nurse suspect? Appendicitis Pancreatitis Hirschsprung disease Gastroenteritis
Gastroenteritis
The nurse is developing a teaching plan for the parents of an 11-month-old infant with gastroesophageal reflux disease (GERD). The infant will be managed medically. What action(s) will the nurse incorporate into the teaching plan? Select all that apply. Give the child small frequent feedings. Administer omeprazole after meals. Keep the child upright for 30 minutes after feeding. Thin the formula with water to ease the flow. Administer a prokinetic to empty the stomach quickly.
Give the child small frequent feedings. Keep the child upright for 30 minutes after feeding. Administer a prokinetic to empty the stomach quickly.
A nurse prepares a menu for a client with Crohn disease. What is the focus of dietary management for this disease? High carbohydrate, high protein High calorie, high fiber Low calorie, high carbohydrate Low fiber, low calorie
High carbohydrate, high protein
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? Ulcerative colitis (UC) Short bowel syndrome (SBS) Gastroenteritis Hirschsprung disease
Hirschsprung disease
A child is hospitalized with dehydration as a result of rotavirus. When reviewing the plan of treatment, what can the nurse anticipate will be included? Select all that apply. antibiotic therapy IV fluid administration antidiarrheal agents monitor of intake and output daily weight assessment
IV fluid administration monitor of intake and output daily weight assessment
The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time? Improving hydration Preparing family for home care Promoting comfort Maintaining skin integrity
Improving hydration
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux? A partial or complete intestinal obstruction occurs. A thickened, elongated muscle causes an obstruction at the end of the stomach. There are recurrent paroxysmal bouts of abdominal pain. In this disorder the sphincter that leads into the stomach is relaxed.
In this disorder the sphincter that leads into the stomach is relaxed.
A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case? Volvulus with malrotation Necrotizing enterocolitis Short-bowel/short-gut syndrome Intussusception
Intussusception
A school-aged child is brought to the emergency room with severe abdominal pain. The nurse performs a physical assessment. Which assessment parameters indicate appendicitis? Select all that apply. Rebound tenderness present with palpation in the left upper quadrant Low-grade fever, nausea, anorexia, and vomiting Irritation and pain in the right lower quadrant Hypoactive bowel sounds with perforation Normal to hyperactive bowel sounds early Distended abdomen with unperforated appendicitis
Low-grade fever, nausea, anorexia, and vomiting Irritation and pain in the right lower quadrant Hypoactive bowel sounds with perforation Normal to hyperactive bowel sounds early
A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant? Lower right Upper right Upper left Lower left
Lower right
A 3-month-old girl is found to have an umbilical hernia at a well visit. On examination, the nurse discovers that the fascial ring through which the intestine protrudes is about 1 cm in diameter. Which statement by the nurse to the girl's father would indicate the likely intervention required to correct this condition? No intervention is needed, as the opening will most likely close spontaneously. Wrapping an elastic band around the child's waist should correct the problem. Surgery at age 1 to 2 years will likely be needed to repair the condition. Taping a silver dollar over the area will help reduce the hernia.
No intervention is needed, as the opening will most likely close spontaneously.
A nurse manages the interdisciplinary care for an infant born with an omphalocele. Which action should the nurse perform? Protect the exposed bowel by gently manipulating it back into the abdominal cavity. Administer corticosteroids as prescribed—either oral prednisone or prednisolone or as IV methylprednisolone. Ensure the newborn is always lying on their back with proper support. Obtain IV access to give fluid resuscitation and correct any electrolyte abnormalities.
Obtain IV access to give fluid resuscitation and correct any electrolyte abnormalities.
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting? Is curdled and extremely sour smelling Only occurs with feeding Continues until stomach is empty Is projected 1 ft away from infant
Only occurs with feeding
The nurse is caring for a teenager diagnosed with acute pancreatitis. Which order would the nurse question? NPO nasogastric tube placed to suction serum amylase levels PO pain management
PO pain management
The nurse is performing an assessment on a child suspected of having an inguinal hernia. Which assessment technique(s) should be used to assess for the presence of the hernia? Select all that apply. Ask the child to hold the breath and grunt forcefully. Press the palm of one hand on the abdomen and then withdraw the hand. Ask the child to inhale forcefully while the inguinal canal is palpated. Palpate the inguinal canal while the child blows up a balloon. Palpate the inguinal canal and ask the child to turn the head and cough.
Palpate the inguinal canal while the child blows up a balloon. Palpate the inguinal canal and ask the child to turn the head and cough.
The nurse is caring for a child admitted with congenital aganglionic megacolon. Which clinical manifestation would likely have been noted in the child with this diagnosis? Prolonged bleeding Irregular breathing Persistent constipation Chronic cough
Persistent constipation
The nurse is examining a 7-year-old with suspected appendicitis. Which physical findings would indicate the possibility of appendicitis? Diffuse, intermittent abdominal pain Persistent, right lower quadrant pain with rebound tenderness Tenderness that comes and goes in the lower abdomen Intermittent, left lower quadrant pain with rebound tenderness
Persistent, right lower quadrant pain with rebound tenderness
The emergency department nurse is assessing a child who has presented with a 2-day history of nausea and vomiting with pain that is isolated to the right upper quadrant of the abdomen. Which action is most appropriate? Administer antacids as ordered. Prepare the child for admission to the hospital. Encourage fluid intake. Assess the child's usual urinary voiding pattern.
Prepare the child for admission to the hospital.
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention? Assist in insertion of a nasogastric (NG) tube. Prepare the infant for surgery. Change the infant's diet to one that is lactose-free. Assist in doing a barium enema procedure on the infant.
Prepare the infant for surgery.
A 12-year-old boy has just undergone a liver transplantation and is recovering. After performing a fingerstick puncture and assessing the results, the nurse administers a 10% solution of dextrose IV. What is the correct rationale for this intervention? Prevention of hypoglycemia Reduction of hypertension Prevention of T-cell rejection of the transplanted liver Maintenance of electrolyte balance
Prevention of hypoglycemia
The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis? Frequent urination Projectile vomiting Severe abdominal pain Explosive diarrhea
Projectile vomiting
The nurse is caring for a 6-month-old infant with diarrhea and dehydration. The parent is concerned because the infant has some patches on the tongue. Which feature indicates a geographic tongue? There are also white patches on the erupted teeth. The patches are thick, white plaques on the tongue. There are also plaques on the buccal mucosa. Some patches are light in color and other patches are dark in color.
Some patches are light in color and other patches are dark in color.
An adolescent has hepatitis B. What would be the most important nursing action? Strict calculation of caloric and vitamin B intake Strict enforcement of standard precautions Conscientious collection of stool for ova and parasites Close observation to detect cerebral hallucinations
Strict enforcement of standard precautions
The nurse is caring for a 6-month-old infant who was admitted to the emergency department 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104°F (40°C), with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which is the priority nursing intervention? Feed the child a cracker Administer antibiotic therapy Take a stool culture Administer IV potassium
Take a stool culture
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration? Pale and slightly dry mucosa Soft and flat fontanels (fontanelles) Tenting of skin Blood pressure of 80/42 mm Hg
Tenting of skin
An adolescent is diagnosed with hepatitis A. Which problem should be considered when planning care? Hypothermia is common. The adolescent will be very irritable and perhaps require sedation. The adolescent's urine will be dark and infectious. The adolescent will become fatigued easily.
The adolescent will become fatigued easily.
A nurse explains to the family of an infant with an inguinal hernia that the surgeon will attempt manual reduction prior to surgical repair. Which statement describes this technique? The client is sedated, the lower torse is elevated, and the incarcerated contents of the hernia are manipulated back into the peritoneal cavity. The client is sedated, the lower torso is lowered, and the contents of the hernia are manipulated back into the peritoneal cavity. The client is sedated, the lower torso is elevated, and the contents are gently manipulated back into the stomach. The client is sedated, an incision is made in the peritoneal cavity, and the contents are gently manipulated back into the stomach.
The client is sedated, the lower torso is elevated, and the contents are gently manipulated back into the stomach.
The newborn was diagnosed with esophageal atresia and a nasogastric tube was inserted. Which findings are most consistent with this condition? Select all that apply. The newborn's mouth was very dry. The newborn coughed excessively during attempts to feed. Coarse crackles were auscultated throughout all lung fields. The newborn's skin was very jaundiced. X-ray revealed that the nasogastric tube was coiled in the upper esophagus.
The newborn coughed excessively during attempts to feed. Coarse crackles were auscultated throughout all lung fields. X-ray revealed that the nasogastric tube was coiled in the upper esophagus.
The nurse is caring for a newborn following delivery who has been diagnosed with gastroschisis. Which action(s) by the nurse indicates knowledge of appropriate care for this disorder? Select all that apply. The nurse assesses the color of the newborn's abdominal organs. The nurse covers the abdominal contents with a nonadherent clean dressing to prevent infection. The nurse places the newborn in a radiant warmer to maintain the newborn's temperature. The nurse notifies the parents that surgical repair will be done when the newborn reaches 1 month of age. The nurse closely monitors the hydration status of the newborn for signs of dehydration.
The nurse assesses the color of the newborn's abdominal organs. The nurse places the newborn in a radiant warmer to maintain the newborn's temperature. The nurse closely monitors the hydration status of the newborn for signs of dehydration.
What occurs in the gastrointestinal system of the child with Hirschsprung disease? There is a relaxed sphincter in the lower portion of the esophagus. There is an invagination or telescoping of one portion of the bowel into a distal portion. There is a severe narrowing of the lumen of the pylorus. There is a partial or complete mechanical obstruction in the intestine.
There is a partial or complete mechanical obstruction in the intestine.
The nurse is talking with a pregnant client about cleft lips and palates. The client has asked if these can be tested for. What information should be included in the nurse's response? Select all that apply. There are no ways to determine the presence of cleft lips or palates prior to delivery. The quadruple marker test can be used to detect these conditions. Ultrasounds can be used to assess for these conditions. The nuchal translucency test can be used to screen for cleft lips and palates. Most cleft lips and palates are found at delivery.
Ultrasounds can be used to assess for these conditions. Most cleft lips and palates are found at delivery.
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described? Vomiting immediately after feeding Refusal to eat Chronic diarrhea Vomiting about 2 hours after feeding
Vomiting immediately after feeding
A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting blood. A medical history determines that the 3-year-old has no history of GI disturbances and his only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these symptoms, what condition might the nurse suspect? GI tract obstruction intussusception gastroesophageal reflux acute upper GI bleeding
acute upper GI bleeding
A nurse is caring for a child hospitalized with acute pancreatitis. Which intervention(s) in the care plan would alert the nurse to clarify with the provider? Select all that apply. obtain consent for abdominal ultrasound discontinue intravenous fluids if nasogastric tube is present monitor serum amylase and serum lipase maintain strict NPO status administer intravenous analgesics for pain administer intravenous corticosteroids
administer intravenous corticosteroids discontinue intravenous fluids if nasogastric tube is present
A 3-year-old child has been brought to the clinic for assessment of chronic constipation. After ruling out an organic cause, what will the nurse prioritize in the child's plan of care? teaching the child's caregivers how to safely administer an enema teaching the child habits that promote normal bowel function teaching the child's caregivers the need to toilet the child hourly during the day administering over-the-counter stool softeners but for no longer than 1 week
administering over-the-counter stool softeners but for no longer than 1 week
The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. What food will the nurse recommend as an appropriate diet choice? canned soup oatmeal bananas toast
bananas
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which foods would be permitted in the diet of the child with celiac syndrome? Select all that apply. bananas applesauce skim milk rye bread wheat bread
bananas applesauce skim milk
A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? determine esophageal contractility evaluate gastric pH confirm pancreatitis detect Helicobacter pylori
detect Helicobacter pylori
The labor and delivery nurse is caring for a mother who has demonstrated polyhydramnios upon delivery. The newborn displays copious, frothy bubbles of mucus in the mouth and nose, as well as drooling. The nurse is concerned that the infant has what disorder? omphalocele gastroschisis esophageal atresia hiatal hernia
esophageal atresia
A nurse examining a neonate is unable to identify the fetal stomach. The nurse knows that this sign strongly indicates which condition? pyloric stenosis esophageal atresia (EA) hernia duodenal atresia
esophageal atresia (EA)
A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate? pyloric stenosis esophageal atresia (EA) cleft palate hernia
esophageal atresia (EA)
The nurse is caring for a 12-year-old child with Crohn disease. What assessment finding will the nurse report to the health care provider when caring for the child? no joint swelling fever clear lung sounds report of a headache
fever
The nurse is caring for a 2-year-old child with a gastrointestinal infection resulting in 4 to 5 liquid stools per day over the past 3 days. Based on this information, which important concern(s) will the nurse address in the child's care? Select all that apply. availability of parents to care for the child fluid deficiency risk: dehydration undernourishment risk: malnutrition diarrhea and loss of electrolytes the risk for skin maceration in the perineum
fluid deficiency risk: dehydration diarrhea and loss of electrolytes the risk for skin maceration in the perineum
An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to: gastroesophageal reflux disease. cystic fibrosis. Hirschsprung disease. inflammatory bowel disease.
gastroesophageal reflux disease.
The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis? sausage-shaped mass in the upper mid abdomen hard, moveable "olive-like mass" in the upper right quadrant abdominal pain and irritability perianal fissures and skin tags
hard, moveable "olive-like mass" in the upper right quadrant
The nurse recommends rotavirus vaccine for which group of clients? toddlers neonates infants preschoolers
infants
The parent reports that the health care provider said that the infant had a hernia but cannot remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated? hiatal hernia umbilical hernia diaphragmatic hernia inguinal hernia
inguinal hernia
A parent brings the 10-year-old child in to the clinic. The nurse notes: icteric sclera and skin, headache, anorexia, vomiting, and temperature 101.8°F (38.8°C). The parent states the child has had the symptoms since returning to the US from India a few days ago. The nurse will anticipate preparing the child for which test? liver function tests magnetic resonance imaging (MRI) abdominal ultrasound fecal ova and parasite test
liver function tests
A child with severe vomiting for 3 days presents with hypopnea and hypokalemia. The nurse reports to the provider that this child is exhibiting signs of which condition? metabolic acidosis respiratory acidosis metabolic alkalosis respiratory alkalosis
metabolic alkalosis
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition? maternal use of acetaminophen in third trimester mother age 42 with pregnancy history of hypoxia at birth preterm birth
mother age 42 with pregnancy
A child has been admitted to the acute care facility for the management of dehydration. The nurse is preparing to administer IV fluid replacement to the child. Which fluid(s) is suitable for use? Select all that apply. normal saline 5% dextrose in water 0.45% saline lactated Ringer's 10% dextrose in water
normal saline lactated Ringer's
A toddler is being seen in the clinic. The parents describe a 2-day history of vomiting and diarrhea. The nurse's assessment finds the toddler is listless, has pale and slightly dry mucous membranes, and has decreased skin turgor. Based on this assessment, what intervention would the nurse implement first? administer an antiemetic bolus IV fluids administer an antidiarrheal oral rehydration therapy
oral rehydration therapy
The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is: painless rectal bleeding. ischemia. respiratory distress. dehydration.
painless rectal bleeding.
A child with liver cirrhosis is admitted to the acute care facility in preparation for a liver transplant. What finding(s) would the nurse document after completing this child's assessment? Select all that apply. palms of hands reddened yellow skin and sclera fatty, foul-smelling stool confused mental status liver palpable
palms of hands reddened yellow skin and sclera confused mental status liver palpable
A parent brings a 10-year-old child to the emergency room with reports of abdominal pain. The nurse performing a physical assessment notes the following symptoms: upper right quadrant pain that radiates to the back; fever; nausea; and abdominal distention. Which disease would the nurse suspect? ulcerative colitis pancreatitis appendicitis Crohn disease
pancreatitis
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child? gastroesophageal reflux pyloric stenosis appendicitis peptic ulcer disease
pyloric stenosis
The parents of a 4-week-old report that their infant has forceful vomiting but seems very hungry immediately after vomiting. Upon further questioning, the nurse notifies the physician of the findings and pyloric stenosis is suspected. The nurse prepares the parents for the possibility of which diagnostic procedures and treatment? CT scan pyloric ultrasound physical examination of the abdomen upper GI series surgical repair
pyloric ultrasound physical examination of the abdomen upper GI series surgical repair
The nurse is reviewing the history of a child who has chronic oral lesions. What risk factors does the nurse expect to find when reviewing the child's history? Select all that apply. history of anemia recently finished the last chemotherapy treatment for leukemia several episodes of tonsillitis severe malabsorption from a GI disorder frequent bouts of constipation
recently finished the last chemotherapy treatment for leukemia severe malabsorption from a GI disorder
The nurse is reviewing the history of a child who has chronic oral lesions. What risk factors does the nurse expect to find when reviewing the child's history? Select all that apply. several episodes of tonsillitis recently finished the last chemotherapy treatment for leukemia severe malabsorption from a GI disorder history of anemia frequent bouts of constipation
recently finished the last chemotherapy treatment for leukemia severe malabsorption from a GI disorder
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has: malabsorption syndrome. failure to thrive. risk for fluid volume deficit. severe dehydration.
severe dehydration.
The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is: severe diarrhea. steatorrhea. projectile stools. currant jelly stools.
steatorrhea.
A child is diagnosed with short bowel syndrome. What treatment(s) should the nurse expect to be included in the child's plan of care? Select all that apply. total parenteral nutrition laxatives vitamin supplements antibiotics immunosuppressants
total parenteral nutrition vitamin supplements antibiotics
