Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which description of stool is characteristic of intussusception?
A. Loose, foul-smelling stools.
Loose, foul-smelling stools are not characteristic of intussusception. Intussusception is a condition in which a part of the intestine invaginates into another part, causing obstruction. This obstruction often leads to "currant jelly" stools, which are composed of mucus, blood, and sloughed intestinal tissue. Loose stools might be associated with other gastrointestinal issues but are not a hallmark of intussusception.
B. Ribbon-like stools.
Ribbon-like stools are characteristic of intussusception. When a section of the intestine telescopes into another section, it can cause the stool to be squeezed into a ribbon-like shape as it passes through the narrowed portion. This description aligns with the pathophysiology of intussusception.
C. Hard stools positive for guaiac.
Hard stools positive for guaiac indicate the presence of blood in the stool, but this finding is not specific to intussusception. Guaiac testing detects occult blood, which could be present in various gastrointestinal conditions, including bleeding ulcers or diverticulitis, and not exclusively in intussusception.
D. "Currant jelly" stools.
"Currant jelly" stools are characteristic of intussusception. As mentioned earlier, these stools are the result of the obstruction and subsequent damage to the intestinal lining, leading to the presence of blood, mucus, and sloughed tissue. This description is a classic sign of intussusception and should raise suspicion for this condition.
This question is an excerpt from Nurse Dive's nursing test bank - Pediatrics Midterm V1 2023 Test 3 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice D. "Currant jelly" stools.
Choice A rationale:
Loose, foul-smelling stools are not characteristic of intussusception. Intussusception is a condition in which a part of the intestine invaginates into another part, causing obstruction. This obstruction often leads to "currant jelly" stools, which are composed of mucus, blood, and sloughed intestinal tissue. Loose stools might be associated with other gastrointestinal issues but are not a hallmark of intussusception.
Choice B rationale:
Ribbon-like stools are characteristic of intussusception. When a section of the intestine telescopes into another section, it can cause the stool to be squeezed into a ribbon-like shape as it passes through the narrowed portion. This description aligns with the pathophysiology of intussusception.
Choice C rationale:
Hard stools positive for guaiac indicate the presence of blood in the stool, but this finding is not specific to intussusception. Guaiac testing detects occult blood, which could be present in various gastrointestinal conditions, including bleeding ulcers or diverticulitis, and not exclusively in intussusception.
Choice D rationale:
"Currant jelly" stools are characteristic of intussusception. As mentioned earlier, these stools are the result of the obstruction and subsequent damage to the intestinal lining, leading to the presence of blood, mucus, and sloughed tissue. This description is a classic sign of intussusception and should raise suspicion for this condition.
Similar Questions
When caring for the child with Kawasaki disease, the nurse should understand what principle of care?
A. The child's fever is usually responsive to antibiotics within 48 hours.
The child's fever in Kawasaki disease is not usually responsive to antibiotics within 48 hours. Kawasaki disease is an inflammatory condition of blood vessels, and it doesn't typically respond to antibiotics. The fever associated with Kawasaki disease often persists even with appropriate treatment, and the management focuses on reducing inflammation and preventing complications.
B. Aspirin is contraindicated.
Aspirin is not contraindicated in Kawasaki disease. In fact, aspirin is a key component of the therapeutic management of Kawasaki disease. It is used to reduce inflammation and prevent the development of coronary artery aneurysms, a severe complication of the disease. However, the dosing of aspirin in Kawasaki disease is different from its use for pain relief, and it should be administered under medical supervision.
C. Therapeutic management includes administration of gamma globulin and aspirin.
Therapeutic management of Kawasaki disease does include administration of gamma globulin and aspirin. Gamma globulin is given to reduce the risk of coronary artery involvement and aneurysm formation. Aspirin, at a specific dose regimen, is used to decrease inflammation and platelet aggregation, thus preventing clot formation in the coronary arteries.
D. The principal area of involvement is the joints.
The principal area of involvement in Kawasaki disease is not the joints. Kawasaki disease primarily affects the blood vessels, particularly the coronary arteries. The inflammation of these arteries can lead to the development of coronary artery aneurysms, which is a critical concern in Kawasaki disease. Joint involvement is not a prominent feature of this condition.
Full Explanation
The correct answer is choice C. Therapeutic management includes administration of gamma globulin and aspirin.
Choice A rationale:
The child's fever in Kawasaki disease is not usually responsive to antibiotics within 48 hours. Kawasaki disease is an inflammatory condition of blood vessels, and it doesn't typically respond to antibiotics. The fever associated with Kawasaki disease often persists even with appropriate treatment, and the management focuses on reducing inflammation and preventing complications.
Choice B rationale:
Aspirin is not contraindicated in Kawasaki disease. In fact, aspirin is a key component of the therapeutic management of Kawasaki disease. It is used to reduce inflammation and prevent the development of coronary artery aneurysms, a severe complication of the disease. However, the dosing of aspirin in Kawasaki disease is different from its use for pain relief, and it should be administered under medical supervision.
Choice C rationale:
Therapeutic management of Kawasaki disease does include administration of gamma globulin and aspirin. Gamma globulin is given to reduce the risk of coronary artery involvement and aneurysm formation. Aspirin, at a specific dose regimen, is used to decrease inflammation and platelet aggregation, thus preventing clot formation in the coronary arteries.
Choice D rationale:
The principal area of involvement in Kawasaki disease is not the joints. Kawasaki disease primarily affects the blood vessels, particularly the coronary arteries. The inflammation of these arteries can lead to the development of coronary artery aneurysms, which is a critical concern in Kawasaki disease. Joint involvement is not a prominent feature of this condition.
What is a common, serious complication of rheumatic fever?
A. Pulmonary hypertension.
Pulmonary hypertension is not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart, joints, skin, and brain, and pulmonary hypertension is not a typical manifestation of this condition.
B. Cardiac valve damage.
Cardiac valve damage is a common and serious complication of rheumatic fever. Rheumatic fever is caused by an autoimmune reaction to untreated streptococcal infections, particularly Streptococcus pyogenes. The immune response targets not only the streptococcal bacteria but also the body's own tissues, especially heart valves. This can lead to inflammation of the heart valves, a condition known as rheumatic heart disease. Over time, repeated bouts of rheumatic fever can result in significant damage to the heart valves, leading to valve insufficiency or stenosis. This can ultimately cause heart failure and other cardiovascular complications.
C. Seizures.
Seizures are not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart and other body systems, but it does not typically lead to seizures.
D. Cardiac arrhythmias.
Cardiac arrhythmias are possible complications of rheumatic fever, but they are not as common or significant as cardiac valve damage. The inflammation and scarring caused by rheumatic fever can disrupt the electrical pathways of the heart, potentially leading to arrhythmias. However, the more prevalent and severe consequence of rheumatic fever is the damage to the heart valves.
Full Explanation
The correct answer is choice B. Cardiac valve damage.
Choice A rationale:
Pulmonary hypertension is not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart, joints, skin, and brain, and pulmonary hypertension is not a typical manifestation of this condition.
Choice B rationale:
Cardiac valve damage is a common and serious complication of rheumatic fever. Rheumatic fever is caused by an autoimmune reaction to untreated streptococcal infections, particularly Streptococcus pyogenes. The immune response targets not only the streptococcal bacteria but also the body's own tissues, especially heart valves. This can lead to inflammation of the heart valves, a condition known as rheumatic heart disease. Over time, repeated bouts of rheumatic fever can result in significant damage to the heart valves, leading to valve insufficiency or stenosis. This can ultimately cause heart failure and other cardiovascular complications.
Choice C rationale:
Seizures are not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart and other body systems, but it does not typically lead to seizures.
Choice D rationale:
Cardiac arrhythmias are possible complications of rheumatic fever, but they are not as common or significant as cardiac valve damage. The inflammation and scarring caused by rheumatic fever can disrupt the electrical pathways of the heart, potentially leading to arrhythmias. However, the more prevalent and severe consequence of rheumatic fever is the damage to the heart valves.
The nurse, caring for an infant whose cleft lip was repaired, should include which interventions in the infant's postoperative plan of care? (Select all that apply.).
A. Petroleum jelly to the suture line.
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
B. Elbow restraints.
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
C. Supine and side-lying positions.
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
D. Mouth irrigations.
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
E. Postural drainage.
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.
Full Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
Choice B rationale:
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
Choice C rationale:
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
Choice D rationale:
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
Choice E rationale:
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.