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2.
3.
1. A. CORRECT: A client who has a pyloric stricture has thickening of the pyloric
sphincter, resulting in projectile vomiting.
B. CORRECT: A client who has pyloric stricture is unable to consume adequate food and
fluid, resulting in dehydration. Dry mucous membranes is a clinical manifestation of
hypertrophic pyloric stenosis.
C. INCORRECT: A client who has intussusception have bloody mucus stools, resulting in
currant jelly stools.
D. INCORRECT: A client who has intussusception have telescoping intestine, resulting
sausage shaped abdominal mass.
E. CORRECT: A client who has pyloric stricture is unable to consume adequate food and
fluid, resulting in constant hunger.
NCLEX Connection: Physiological Adaptations, Pathophysiology
2. A. INCORRECT: A client who has Hirschsprung disease is encouraged to eat a lowfiber, high-protein, high-calorie diet.
B. CORRECT: A client who has Hirschsprung disease requires surgery to remove the
affected segment of the intestine. Preparing the family for surgery is an appropriate action
for the nurse to take.
C. INCORRECT: A client who has Hirschsprung disease is managed nutritionally.
Placing an NG for decompression is not an appropriate action for the nurse to take.
D. INCORRECT: A client who has Meckel's diverticulum is placed on bedrest to prevent
further bleeding.
NCLEX Connection: Reduction of Risk Potential, Therapeutic Procedures
1. Diarrhea
2. Projectile vomiting
3. Regurgitation of feedings
4. Foul-smelling ribbon-like stools
4.
5.
3. Metabolic alkalosis
Rationale:
Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis.
Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of
bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel
sounds are not associated with vomiting.
2. Projectile vomiting
Rationale:
In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing
of the pyloric canal between the stomach and the duodenum. Clinical manifestations of
pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation,
and signs of dehydration including a decrease in urine output.
6.
7.
8.
9.
3. "Does the vomit contain sour undigested food without bile, and is the infant
constipated?"
Rationale:
Option 3 presents classic symptoms of pyloric stenosis. Stools that are ribbonlike and a child who is eating poorly are signs of congenital megacolon
(Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and
draws the legs up to chest is demonstrating physical signs of intussusception.
Crying during the evening hours, appearing to be in pain, eating well, and
gaining weight are clinical manifestations of colic.
10.
4. "Can you describe the type of pain that the child is experiencing?"
Rationale:
A report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months
of age is the classic presentation of intussusception. Typical behavior includes screaming and
drawing the knees up to the chest. Options 1, 2, and 3 are important aspects of a health history
but are not specific to the diagnosis of intussusception.
1. "Special cells are not present in the rectum, which caused the disease."
Rationale:
Hirschsprung's disease also is known as congenital aganglionosis or megacolon. It results
from the absence of ganglion cells in the rectum and, to various degrees, up into the colon.
Option 2 describes celiac disease. Option 3 describes irritable bowel syndrome. Option 4
describes lactose intolerance.
13.
14.
15.
16.
2. Metabolic alkalosis
Rationale:
Laboratory findings in an infant with hypertropic pyloric stenosis
include metabolic alkalosis as a result of the vomiting that occurs in
this disorder. Additional findings include decreased serum
potassium and sodium levels, increased pH and bicarbonate level,
and decreased chloride level. Options 1, 3, and 4 are incorrect.
1. Blood pH of 7.50
Rationale:
Laboratory findings in an infant with hypertrophic pyloric stenosis
include metabolic alkalosis due to vomiting. These include increased
blood pH and bicarbonate level, decreased serum potassium and
sodium levels, and a decreased chloride level. The normal pH is 7.35
to 7.45. The normal bicarbonate is 22 to 27 mm Hg.
18.
19.
21.
Answer: 2,1,4,3
Rationale
Assessment of the abdomen should include inspection first to observe for contour,
symmetry, and any skin abnormalities. Auscultation is the next step. This is done
prior to palpation and percussion to prevent the alteration of bowel sound. Next,
palpation is used to detect any tenderness or rigidity. Finally, percussion is performed
to determine if any fluid, distention, or masses exist. (Lewis, et al, 8 ed., p. 908910.)
Answer: 4
Rationale This option focuses on therapeutic communication: a reflective, clarifying
comment about what the mother has just said and encouragement to describe her
feelings. The question asks for interpretation of mothers comment. The other options
do not encourage expression of feelings, or they are blocks to therapeutic
communication. (Potter, Perry, ed., p. 32.)
22.
A 6weekold infant is
brought by her parent into
the clinic. The parent
explains to the nurse that
after feedings the infant
vomits real strong. The
nurse recognizes the
symptoms of projectile
vomiting. The nurse would
correlate this symptom
with what condition?
1. Tracheoesophageal
fistula
2. Pyloric stenosis
3. Intussusception
4. Volvulus
Answer: 2
Rationale
Vomiting in an infant with pyloric stenosis begins to develop between 4 and 6 weeks of age. The
vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet.
Breastfed infants begin developing symptoms at approximately 6 weeks, because the curd of breast milk
is smaller than that of cow's milk, and it passes through a hypertrophied muscle more easily. Symptoms
of volvulus often follow those related to intestinal obstruction and include constipation, colicky
abdominal pain, nausea, and abdominal distention. Symptoms of intussusception are characterized by
sudden, severe abdominal pain vomiting and abdominal distention infant may pass a bloody stool (i.e.,
currant-jelly appearance). Symptoms of tracheoesophageal fistula include choking, coughing, and
intermittent cyanosis during feeding, along with abdominal distention these are diagnosed most often at
birth with the first feeding. (Hockenberry, Wilson, 9 ed., p. 1322.)