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
Explanation
The correct answer is A. Potential Condition.
The infant’s symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant’s neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.
Correct Answer is D
Explanation
Choice A rationale
The incubation period for varicella, or chickenpox, is typically longer than 2 to 5 days. It usually ranges from 10 to 21 days.
Choice B rationale
An incubation period of 3 to 4 weeks is within the typical range for varicella. However, the average incubation period is usually around 14 to 16 days.
Choice C rationale
An incubation period of 7 to 10 days is shorter than the typical incubation period for varicella, which is usually around 14 to 16 days.
Choice D rationale
An incubation period of 2 to 3 weeks is within the typical range for varicella. The average incubation period is usually around 14 to 16 days.
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