1. The clinic nurse supervises a graduate nurse who is teaching the parents of a 2-year-old with acute diarrhea about home management. The nurse would need to intervene when the graduate nurse provides which instruction?
    1. "Do not administer antidiarrheal medications to your child."
    2. "Follow the bananas, rice, applesauce, and toast diet for the next few days."
    3. "Record the number of wet diapers and return to the clinic if you notice a decrease."
    4. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides."
    • Answer 2
    • During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, using oral rehydration solutions (ORSs) to increase reabsorption of water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at frequent intervals. Continuing the child's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy.
    • (Option 1) Use of antidiarrheal medications is discouraged as these have little effect in controlling diarrhea and may actually be harmful by prolonging some bacterial infections and causing fatal paralytic ileus in children.
    • (Option 3) Parents should be taught to monitor their child for signs of dehydration by checking the amount of fluid intake, number of wet diapers, presence of sunken eyes, and the condition of the mucous membranes.
    • (Option 4) Protecting the perineal skin from breakdown during bouts of diarrhea can be accomplished by using skin barrier creams (eg, petrolatum or zinc oxide).
    • Educational objective:
    • When a child is experiencing acute diarrhea, the priority is to monitor for dehydration. Treatment is accomplished with oral rehydration solutions and early reintroduction of the child's normal diet (usual foods).
  2. The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting surgery. Which assessment finding requires the nurse's immediate action?
    1. Abdominal distension with no change in girth for 8 hours
    2. Did not pass meconium or stool within 48 hours after birth
    3. Episode of foul-smelling diarrhea and fever
    4. Excessive crying and greenish vomiting
    • Answer 3
    • Rationale:¬†Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required.
    • A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal distension.
    • (Option 1) Mild to moderate abdominal distension is an expected finding with a diagnosis of HD; however, increasing abdominal girth is a serious finding that must be reported.
    • (Option 2) Failure to pass meconium or stool within 24-48 hours after birth is an expected finding of HD.
    • (Option 4) Bilious vomiting and excessive crying are expected findings of HD. In enterocolitis, vomiting can occur more frequently and the client appears more ill.
    • Educational objective:
    • Enterocolitis, a potentially fatal complication of Hirschsprung disease, is characterized by explosive, foul-smelling diarrhea; fever; and worsening abdominal distension.
  3. The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP). The caregiver shows understanding of the instructions by contacting the HCP about which symptom?
    1. A temperature of 99 F (37 C) that occurs during the evening
    2. The child cannot recall items eaten for lunch the previous day
    3. The child vomits after awakening from a nap and 1 hour later
    4. The VP shunt is palpated along the posterior-lateral portion of the skull
    • Answer 3
    • Rationale:¬†
    • The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure (ICP), which indicate shunt malfunction. Vomiting may be a sign of increased ICP and would require that the HCP be contacted.
    • (Option 1) Fever may indicate shunt infection, but a temperature of 99 F (37 C) remains within acceptable parameters. Contacting the HCP is not indicated.
    • (Option 2) Memory lapse or changes in mental status may indicate increased ICP. The inability to remember one meal would not indicate a change of mental status.
    • (Option 4) A VP shunt is tunneled under the scalp and can be palpated.
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