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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While it’s true that bone marrow can be lost through a fracture, this is not specific to fractures of the epiphyseal plate.
Choice B rationale
The healing time for fractures in children and adults can vary depending on many factors, but it’s not accurate to say that fractures in children take longer to heal than fractures in adults.
Choice C rationale
Normal bone growth can indeed be affected by a fracture of the epiphyseal plate. The epiphyseal plate, or growth plate, is the area of growing tissue near the ends of the long bones in children and adolescents. When a fracture occurs at the epiphyseal plate, it can disrupt the normal growth of the bone and lead to deformities.
Choice D rationale
While calcium is important for bone health, increasing a child’s calcium intake to 3,000 milligrams daily is not typically recommended as part of the treatment or management of a fracture.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine.
Choice B rationale
Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice C rationale
Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice D rationale
While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
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