Keep Practicing!

When assessing the condition of a six-week-old infant who is suspected of having pyloric stenosis, a nurse would expect to exhibit:

A. Projectile vomiting
B. Distended abdomen
C. Loose stools
D. Hiccoughs

Answer: A. Loose stools and hiccoughs do not indicate pyloric stenosis. The abdomen may or may not be distended.

The nurse is caring for a patient with cirrhosis of the liver and an elevated serum ammonia level. Which of the following nursing diagnoses should the nurse give priority to in this patient's care?

A. Colonic constipation
B. Ineffective thermoregulation
C. Altered thought processes
D. Risk for infection

Answer: C. A major complication of cirrhosis is altered state of consciousness, altered intellectual function, behavior, and personality.