Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the parent to seek health care for the infant?
A. Diarrhea
DiarrheaExplanation: Diarrhea is not a typical sign of Hirschsprung's disease. Instead, the condition is associated with constipation due to the obstructed passage of stool.
B. Regurgitation of feedings
Regurgitation of feedingsExplanation: Regurgitation of feedings is not a characteristic sign of Hirschsprung's disease. It may be seen in other gastrointestinal conditions, but not specifically in this disorder.
C. Projectile vomiting
Projectile vomitingExplanation: Projectile vomiting is not a typical sign of Hirschsprung's disease. It may be associated with conditions such as pyloric stenosis, but it is not a characteristic feature of Hirschsprung's disease.
D. Foul-smelling ribbon-like stools
Foul-smelling ribbon-like stoolsExplanation: Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the rectum and a portion of the colon. The lack of ganglion cells results in functional obstruction, causing stool to accumulate in the affected area. One of the hallmark signs is the presence of foul-smelling, ribbon-like stools, often described as "fecal pellets" or "pellets" due to the obstructed passage of stool.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Paediatric Assessment Proctored Exam 2022. Take the full exam now
Full Explanation
A. Diarrhea
Explanation: Diarrhea is not a typical sign of Hirschsprung's disease. Instead, the condition is associated with constipation due to the obstructed passage of stool.
B. Regurgitation of feedings
Explanation: Regurgitation of feedings is not a characteristic sign of Hirschsprung's disease. It may be seen in other gastrointestinal conditions, but not specifically in this disorder.
C. Projectile vomiting
Explanation: Projectile vomiting is not a typical sign of Hirschsprung's disease. It may be associated with conditions such as pyloric stenosis, but it is not a characteristic feature of Hirschsprung's disease.
D. Foul-smelling ribbon-like stools
Explanation:
Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the rectum and a portion of the colon. The lack of ganglion cells results in functional obstruction, causing stool to accumulate in the affected area. One of the hallmark signs is the presence of foul-smelling, ribbon-like stools, often described as "fecal pellets" or "pellets" due to the obstructed passage of stool.
Similar Questions
Which home care instructions would the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.
A. The child needs to avoid exposure to other illnesses.
The child needs to avoid exposure to other illnesses.Explanation: Children with AIDS have compromised immune systems and are more susceptible to infections. Therefore, it is important to minimize exposure to other illnesses to reduce the risk of infections.
B. Frequent handwashing is important.
Frequent handwashing is important.Explanation: Good hand hygiene helps prevent the spread of infections. Encouraging frequent handwashing is crucial in the care of a child with AIDS.
C. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).
Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).Explanation: Using a bleach solution to clean up body fluid spills helps to disinfect and reduce the risk of transmission of infections. The recommended ratio is 10 parts water to 1 part bleach.
D. Monitor the child's weight.
Monitor the child's weight.Explanation: Monitoring the child's weight is important for assessing nutritional status and overall health. Weight loss may indicate underlying health issues that need attention.
E. The child's immunization schedule will need revision.
Explanation: Children with AIDS may have altered immune function, but the need for immunizations is still crucial. However, live vaccines may need to be avoided. The immunization schedule should be discussed and individualized with the healthcare provider.
F. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention
Explanation: While these symptoms may occur, they should not be dismissed without evaluation. Any changes in the child's health, including symptoms such as fever, malaise, fatigue, weight loss, vomiting, and diarrhea, should be reported to the healthcare provider for appropriate assessment and intervention.
Full Explanation
A. The child needs to avoid exposure to other illnesses.
Explanation: Children with AIDS have compromised immune systems and are more susceptible to infections. Therefore, it is important to minimize exposure to other illnesses to reduce the risk of infections.
B. Frequent handwashing is important.
Explanation: Good hand hygiene helps prevent the spread of infections. Encouraging frequent handwashing is crucial in the care of a child with AIDS.
C. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).
Explanation: Using a bleach solution to clean up body fluid spills helps to disinfect and reduce the risk of transmission of infections. The recommended ratio is 10 parts water to 1 part bleach.
D. Monitor the child's weight.
Explanation: Monitoring the child's weight is important for assessing nutritional status and overall health. Weight loss may indicate underlying health issues that need attention.
E. The child's immunization schedule will need revision.
Explanation: Children with AIDS may have altered immune function, but the need for immunizations is still crucial. However, live vaccines may need to be avoided. The immunization schedule should be discussed and individualized with the healthcare provider.
F. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.
Explanation: While these symptoms may occur, they should not be dismissed without evaluation. Any changes in the child's health, including symptoms such as fever, malaise, fatigue, weight loss, vomiting, and diarrhea, should be reported to the healthcare provider for appropriate assessment and intervention.
The parent of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response would the nurse make?
A. The child is too young to receive antibiotics
The child is too young to receive antibiotics: This statement doesn't address the actual reason for not prescribing antibiotics for croup, which is primarily due to its viral nature.
B. "Antibiotics are not indicated unless a bacterial infection is present.
"Antibiotics are not indicated unless a bacterial infection is present." Explanation:Viral laryngotracheobronchitis, commonly known as croup, is typically caused by a viral infection, most commonly by the parainfluenza virus. Antibiotics are not effective against viruses. Therefore, unless a bacterial infection is also present, prescribing antibiotics is not necessary or beneficial in treating croup.
C. The child may be allergic to antibiotics.
The child may be allergic to antibiotics: While antibiotic allergies are a consideration, it doesn't explain why antibiotics are not prescribed for viral illnesses like croup.
D. The child still has the maternal antibodies from birth and does not need antibiotics
The child still has the maternal antibodies from birth and does not need antibiotics: Maternal antibodies can offer some protection against infections, but the primary reason for not using antibiotics in viral infections like croup is because antibiotics are ineffective against viruses.
Full Explanation
A. The child is too young to receive antibiotics: This statement doesn't address the actual reason for not prescribing antibiotics for croup, which is primarily due to its viral nature.
B. "Antibiotics are not indicated unless a bacterial infection is present."
Explanation:
Viral laryngotracheobronchitis, commonly known as croup, is typically caused by a viral infection, most commonly by the parainfluenza virus. Antibiotics are not effective against viruses. Therefore, unless a bacterial infection is also present, prescribing antibiotics is not necessary or beneficial in treating croup.
C. The child may be allergic to antibiotics: While antibiotic allergies are a consideration, it doesn't explain why antibiotics are not prescribed for viral illnesses like croup.
D. The child still has the maternal antibodies from birth and does not need antibiotics: Maternal antibodies can offer some protection against infections, but the primary reason for not using antibiotics in viral infections like croup is because antibiotics are ineffective against viruses.
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?
A. carry a water bottle with me because I drink a lot of water."
"Carry a water bottle with me because I drink a lot of water." Explanation: Staying hydrated is crucial, especially for individuals with paralysis who may be prone to urinary issues. Carrying a water bottle is a good practice to maintain adequate hydration.
B. use a suppository every night to have a bowel movement."
"Use a suppository every night to have a bowel movement." Explanation: Using a suppository for regular bowel movements is a positive self-care behavior. It helps manage bowel care, which is important for individuals with paralysis.
C. I do wheelchair exercises while watching TV."
"I do wheelchair exercises while watching TV."Explanation: Engaging in wheelchair exercises to maintain mobility is a positive self-care behavior. It helps prevent complications related to being sedentary, such as muscle atrophy.
D. only need to catheterize myself twice every day"
"I only need to catheterize myself twice every day."Explanation: This statement may indicate a need for further teaching. Individuals with paralysis, especially due to conditions like spina bifida, often have neurogenic bladder dysfunction. They typically require more frequent catheterization, potentially every 4-6 hours, to ensure adequate bladder emptying and reduce the risk of complications like urinary tract infections (UTIs) or bladder infections.
Full Explanation
A. "Carry a water bottle with me because I drink a lot of water."
Explanation: Staying hydrated is crucial, especially for individuals with paralysis who may be prone to urinary issues. Carrying a water bottle is a good practice to maintain adequate hydration.
B. "Use a suppository every night to have a bowel movement."
Explanation: Using a suppository for regular bowel movements is a positive self-care behavior. It helps manage bowel care, which is important for individuals with paralysis.
C. "I do wheelchair exercises while watching TV."
Explanation: Engaging in wheelchair exercises to maintain mobility is a positive self-care behavior. It helps prevent complications related to being sedentary, such as muscle atrophy.
D. "I only need to catheterize myself twice every day."
Explanation: This statement may indicate a need for further teaching. Individuals with paralysis, especially due to conditions like spina bifida, often have neurogenic bladder dysfunction. They typically require more frequent catheterization, potentially every 4-6 hours, to ensure adequate bladder emptying and reduce the risk of complications like urinary tract infections (UTIs) or bladder infections.
