A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?
Hirschsprung’s disease.
Encopresis.
Pyloric stenosis.
Enterocolitis.
The Correct Answer is A
Choice A rationale
Hirschsprung’s disease is characterized by inadequate motility of part of the intestine, resulting in a mechanical obstruction. This condition is caused by the absence of ganglion cells in the affected segment of the intestine, leading to a lack of peristalsis and subsequent obstruction.
Choice B rationale
Encopresis is a condition characterized by the repeated passage of feces into inappropriate places, such as clothing or the floor. It is not associated with inadequate motility of the intestine or mechanical obstruction.
Choice C rationale
Pyloric stenosis is a condition characterized by the narrowing of the pylorus, which leads to obstruction of the passage of food from the stomach to the small intestine. It is not associated with inadequate motility of the intestine.
Choice D rationale
Enterocolitis is an inflammation of the intestine and colon. It is not associated with inadequate motility of the intestine or mechanical obstruction.
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Correct Answer is C
Explanation
Choice A rationale
Placing the child on a no-salt-added diet is important for managing fluid retention and hypertension in acute glomerulonephritis, but it is not the immediate priority.
Choice B rationale
Educating the parents about potential complications is essential for long-term management, but it is not the immediate priority in an acute setting.
Choice C rationale
Checking the child’s daily weight is the priority action because it helps monitor fluid balance and detect any signs of fluid retention or worsening condition. Accurate daily weight measurements are crucial for assessing the effectiveness of treatment and making necessary adjustments.
Choice D rationale
Maintaining a saline-lock is important for intravenous access, but it is not the immediate priority compared to monitoring fluid balance through daily weight checks.
Correct Answer is B
Explanation
Choice A rationale
Encouraging regular activity level as soon as possible is not appropriate for a child with streptococcal pharyngitis. Rest is important to allow the body to recover and prevent complications.
Choice B rationale
Completing the entire course of antibiotics is crucial to prevent complications such as rheumatic fever, which can result from untreated or partially treated streptococcal infections.
Choice C rationale
Expecting the lymph nodes to swell and obstruct the airway is not a typical outcome of streptococcal pharyngitis. While lymph node swelling can occur, it usually does not obstruct the airway.
Choice D rationale
Being aware that the infection may spread and cause a tooth abscess is not a common complication of streptococcal pharyngitis. The primary concern is preventing complications like rheumatic fever and ensuring complete recovery.