A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority?
Schedule the child for an abdominal ultrasound.
Instruct the parent to avoid pressing on the abdominal area.
Determine if the child is having pain.
Obtain a urine specimen for a urinalysis.
The Correct Answer is B
The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.
Rationale for each choice:
- Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
- Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
- Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
- Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Cold compresses can help relieve joint pain associated with juvenile idiopathic arthritis. Cold therapy can reduce inflammation and numb the affected area, providing temporary relief.
Choice B rationale
This is incorrect. Ibuprofen should not be taken on an empty stomach because it can cause stomach upset or even lead to ulcers or bleeding. It is generally recommended to take ibuprofen with food or milk.
Choice C rationale
Performing range of motion exercises can help maintain joint flexibility and muscle strength in children with juvenile idiopathic arthritis. Regular exercise can also improve overall physical function and well-being.
Choice D rationale
While homeschooling may be a consideration for some families, it is not a general recommendation for all children with juvenile idiopathic arthritis. Many children with this condition can attend regular school with some accommodations as needed.
Choice E rationale
This is correct. Providing extra time for completion of activities of daily living (ADLs) can help children with juvenile idiopathic arthritis manage their symptoms and maintain their independence. It is important to allow children to perform tasks at their own pace to avoid causing unnecessary pain or fatigue.
Correct Answer is D
Explanation
Choice D rationale
When a nurse notes the presence of bruises on a child’s arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
Choice A rationale
Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities.
Choice B rationale
Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse.
Choice C rationale
Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.