Which of the following nursing diagnoses would be inappropriate for the infant with Ger?

1. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea? 1. Notify the physician immediately. 2. Administer antidiarrheal medications. 3. Monitor child ever 30 minutes. 4. Nothing, this is characteristic of Hirschsprung disease Term

1 Notify the physician immediately.

For the child with Hirschsprung disease, fever and explosive diarrhea indicate ________ a _________. Therefore, the physician should be notified immediately. 

enterocolitis, life-threatening situation

why are antidiarrheals not used to treat Hirschsprung disease

Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. Hirschsprung disease typically presents with chronic constipation.

how long does the child with Hirschsprung disease need monitoring? 

The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. 

A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following? a.Hirschsprung disease b. Celiac disease c. Intussusception d. Abdominal wall defect

Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment (related to lack of nerve cells as end of bowel). Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

what are the S&S of Hirschsprung disease

When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information? a.Stool inspection b. Pain pattern c. Family history d. Abdominal palpation

(in-tuh-suh-SEP-shun) is a serious disorder in which part of the intestine slides into an adjacent part of the intestine. (in-tuh-suh-SEP-shun) is a serious disorder in which part of the intestine slides into an adjacent part of the intestine. 

The first sign of intussusception in an otherwise healthy infant?

may be sudden, loud crying caused by abdominal pain. Infants who have abdominal pain may pull their knees to their chests when they cry. 

Other frequent signs and symptoms of intussusception are? 

Stool mixed with blood and mucus (sometimes referred to as "currant jelly" stool because of its appearance)VomitingA lump in the abdomenLethargy

After teaching the parents of a preschooler who has undergone T and A(Tonsillectomy and Adenoidectomy) about appropriate foods to give the child after discharge, which of the following, if stated by the parents as appropriate foods, indicate successful teaching? a)meatloaf and uncooked carrots b) pork and noodle casserole c) cream of chicken soup and orange sherbet d) hot dog and potato chips

Answer C for the first few days after a T and A), liquids and soft foods are best tolerated by the child while the throat is sore. Avoid hard and scratchy foods until throat is healed.

While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised? a.Sucking ability b. Respiratory status c. Locomotion d. GI function

A Because of the defect, the child will be unable to form the mouth adequately around nipple, thereby requiring special devices to allow for feeding and sucking gratification. Respiratory status may be compromised if the child is fed improperly or during postoperative period, Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip

Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux(GER)?  a.Fluid volume deficit b. Risk for aspiration c. Altered nutrition: less than body requirements d. Altered oral mucous membranes

Answer D GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses

When teaching an adolescent with a seizure disorder who is receiving Valproic acid (Depakene), which of the following would the nurse instruct the client to report the health care provider? a)three episodes of diarrhea b) loss of appetite c) jaundice d) sore throat

Answer C A toxic effect of valproic acid (Depakene) is liver toxicity, which may manifest with jaundice and abdominal pain. If jaundice occurs, the client needs to notify the health care provider as soon as possible.

. The parents of a child tell the nurse they feel guilty because their child almost drowned. Which of the following remarks? a)I can understand why you feel guilty, but these things happen b) tell me a bit more about your feelings of guilt c) you should not have taken your eyes off your child d) you really shouldn't fell guilty; you're lucky because your child will be alright

Answer B Guilt is a common parental response. The parents need to be allowed to express their feelings openly in a nonthreatening, nonjudgmental atmosphere.

Which of the following foods would the nurse encourage the mother to offer to her child with iron-deficiency anemia? a) rice cereal, whole milk, and yellow vegetables b) potato, peas, and chicken c) macaroni, cheese and ham d) pudding, green vegetables and rice

Answer B potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice, by itself also is not a good source of iron.

Which of the following statements indicate that the adolescent is showing early signs of anorexia nervosa? a)I have my menses every month b) I go out to eat with my friends c) I run twice a day for a total of 3 hours per day d) I try to maintain my weight around 115 lbs. for my height of 5 feet

Answer C excessive exercise, consumption of very small amounts of food and food rituals, amenorrhea, and excessive weight loss or weight is below normal, lanugo, dry skin, bradycardia, are all signs of anorexia nervosa.

Which of the following signs and symptoms would observe in a child diagnosed of laryngotracheobronchitis? a)predominant stridor on inspiration b) predominant expiratory wheeze c) high fever d) slow respiratory rate

Answer A Because croup cause upper airway obstruction, inspiratory stridor is predominant symptom

Laryngotracheobronchitis What is it.......

(ie, croup) is a viral infection of the upper respiratory tract that causes varying degrees of airway obstruction but that, with aggressive emergent management, only infrequently requires hospital admission.

. Who among the following pediatric clients should be assessed first by the nurse? a) the child with 2 episodes of soft stools during the shift b) the child who had cough for the past three days, with clear nasal discharge and is irritable c) the child with 2 episodes of inconsolable crying while the knees are drawn over the abdomen and plays between the episodes d) the child with skin rashes on his face and trunk

Answer C- this indicates appendicitis. The pattern of abdominal pain in appendicitis is as follows: pain occurs for 2 to 3 hours, pain is relieved in 2 to 3 hours, then pain recurs and persists. During the time that pain subsides is when rupture of appendicitis may occur unnoticed.

what indicates appendicitis?

The pattern of abdominal pain in appendicitis is as follows: pain occurs for 2 to 3 hours, pain is relieved in 2 to 3 hours, then pain recurs and persists. During the time that pain subsides is when rupture of appendicitis may occur unnoticed.

. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following? a.Regurgitation b. Steatorrhea c. Projectile vomiting d. “Currant jelly” stools

Answer C. Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly with GER. Steatorrhea occurs in malabsorption disorders such as celiac disease. “Currant jelly”stools are characteristic of intussusception. Currant jelly stools associated with intusussception – mixed with blood and mucous

. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? A)Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently

Answer C Continue with the present formula The recommended age for switching from formula to whole milk is 12 months. Switching to cow’’s milk before the age of 1 can predispose an infant to allergies and lactose intolerance

In caring for a young child with pain, which assessment tool is the most useful? Simple description pain intensity scale b. 0-10 numeric pain scale c. Faces pain-rating scale d. McGill-Melzack pain questionnaire

ANSWER C – The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and use of advanced vocabulary.

Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux Ger?

Which diagnosis will the nurse document in a patient's care plan that is Nanda I approved?