Question

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. "Tell me about his pain." B. "What does his vomit look like?" C. "Describe his usual diet." D. "Have you noticed changes in his abdominal size?"

Short answer

Answer: "Describe his usual diet."

Step-by-step solution

Understanding intussusception

Intussusception is a medical condition in which a part of the intestine telescopes/folds into another part, causing an intestinal obstruction. Symptoms typically include abdominal pain, vomiting, and changes in stool (such as bloody or mucus-filled). It is essential to understand the condition to determine the relevancy of the questions in identifying it.

Evaluating Option A

Option A: "Tell me about his pain." The presence of abdominal pain is a common symptom of intussusception. This question is relevant and helpful in obtaining information related to the diagnosis.

Evaluating Option B

Option B: "What does his vomit look like?" Vomiting is another symptom associated with intussusception. This question is relevant and helpful in obtaining information about the condition.

Evaluating Option C

Option C: "Describe his usual diet." As the child is 6-months-old, it is less likely that diet is the primary cause of intussusception. Instead, it is often caused by enlarged lymphoid tissue or an abnormal growth in the gut. This question is not as relevant in obtaining information about the diagnosis compared to other options.

Evaluating Option D

Option D: "Have you noticed changes in his abdominal size?" Abdominal distention (swelling) and changes in size could be related to intussusception and the resulting intestinal obstruction. This question is relevant and helpful in getting information about the diagnosis.

Identifying the least helpful question

Based on the evaluation of the options, we can conclude that Option C: "Describe his usual diet." is the least helpful question in obtaining information regarding the diagnosis of intussusception.

Key concepts

Intestinal Obstruction Symptoms

Intestinal obstruction is a critical condition where the passage of food and liquids through the intestine is prevented. When it comes to understanding the symptoms, recognizing them early is key to effective treatment. One major indicator is severe abdominal pain, which may come in waves and be accompanied by a distended or swollen abdomen. The pain might be intense, cramp-like, and persistent, often causing children to draw their knees up to their chest.

Another hallmark symptom is vomiting, which can be bilious (green in color) indicating a blockage high in the intestinal tract. Altered bowel movements, including diarrhea or constipation, and the passage of red, currant jelly-like stools can signal intussusception specifically. Moreover, symptoms like lethargy, irritability, and a palpalble abdominal mass can also be present in such cases. A high index of suspicion for these symptoms in infants and children can aid in the swift diagnosis and treatment of the condition.

Pediatric Nursing Assessment

Pediatric nursing assessment is a cornerstone of child healthcare. It is a holistic evaluation of a child's physical, emotional, and social health, tailored to the specific nuances of pediatric patients. A thorough assessment covers a complete history-taking and examination. The history should include prenatal and birth history, developmental milestones, vaccination status, past medical and surgical history, diet, and family medical history.

During the physical assessment, nurses observe general appearance, vital signs, skin color, and any signs of distress. Specific attention is paid to the abdominal area in cases like intussusception, looking for signs of swelling, tenderness, and the presence of a sausage-shaped mass. From a nursing standpoint, assessment doesn't stop at the physical; it must also consider the child’s comfort and emotional state, as well as parental concerns and family dynamics, creating a supportive environment for care.

NCLEX-PN Examination Preparation

Preparing for the National Council Licensure Examination for Practical Nurses (NCLEX-PN) is a pivotal step in a nursing career. The exam assesses the competency of nursing graduates to begin practice as entry-level licensed practical nurses (LPN)/licensed vocational nurses (LVN). To prepare effectively, you must understand the test format, which consists of multiple-choice questions that cover four major categories including safe and effective care environment, health promotion and maintenance, psychosocial integrity, and physiological integrity.

In preparation for the NCLEX-PN, focus on study plans that include reviewing nursing content, practicing sample questions, and taking practice exams to get accustomed to the test's computer adaptive format. Topics like pediatric nursing, including conditions like intussusception, are within the scope of the exam, so understanding disease processes, signs and symptoms, and appropriate nursing interventions is crucial. Lastly, it's essential to develop test-taking strategies, stress management techniques, and a good study routine to build confidence and ensure success on exam day.