A 3-year-old child is admitted with a Stage II Wilm's tumor. Which preoperative intervention(s) should the nurse implement? Choose all that apply.
Explain expected side effects of postoperative chemotherapy.
Monitor blood pressure every 2 hours for hypertension.
Provide parents with simple explanations and repeat often.
Attend all healthcare provider and parent conferences.
Measure the child's abdominal girth.
Correct Answer : B,C,E
A. Explain expected side effects of postoperative chemotherapy: Chemotherapy and its side effects are typically discussed after surgery when the treatment plan is clearer. The focus before surgery should be on preparing the child and family for the surgery itself.
B. Monitor blood pressure every 2 hours for hypertension: Wilm's tumor can be associated with hypertension due to renin production from the tumor, so monitoring the child's blood pressure closely is essential to detect any signs of hypertension early.
C. Provide parents with simple explanations and repeat often: Simplified, repeated explanations are key to helping parents understand the diagnosis and surgical procedure. This approach supports emotional comfort and ensures informed decision-making.
D. Attend all healthcare provider and parent conferences: While it is important to support the family, the nurse’s role in attending all healthcare provider and parent conferences is not mandatory unless specifically needed for continuity of care.
E. Measure the child's abdominal girth: Measuring abdominal girth is essential preoperatively to monitor for any abdominal changes, such as swelling or distension, which could indicate tumor growth or other complications related to the Wilm's tumor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.
B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.
C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.
D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.
Correct Answer is A
Explanation
A. Request that the mother leave the room: The nurse should prioritize the patient’s needs and comfort, the nurse should calmly request that she leave the room. This allows the nurse to focus on the client’s condition without interference and ensures that the client’s autonomy and wishes are respected.
B. Notify the charge nurse of the situation: While notifying the charge nurse may be appropriate if the situation escalates, the nurse should first try to address the issue directly by requesting that the mother leave the room.
C. Request security to remove her from the room:Security should be a last resort. The situation can likely be handled by the nurse in a calm, respectful manner without the need for security intervention, unless the behavior becomes aggressive or threatening.
D. Tell the mother to stop speaking for the client: This could be perceived as confrontational and disrespectful. It is more effective for the nurse to address the mother’s disruptive behavior by requesting she leave the room so that the client’s privacy and autonomy can be maintained.
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