A nurse is caring for a toddler whose parent states that while bathing the child, she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?
Determine if the child is having pain.
Instruct the parent to avoid pressing on the abdominal area.
Schedule the child for an abdominal ultrasound.
Obtain a urine specimen for analysis.
The Correct Answer is B
The correct answer is: B
Choice A reason: Determining if the child is having pain is important, but it is not the immediate priority. Pain assessment will help in managing the child’s comfort and can provide additional information about the condition. However, in the case of Wilms tumor, which is a common kidney cancer in children, the priority is to prevent any action that could potentially cause tumor spillage or spread.
Choice B reason: Instructing the parent to avoid pressing on the abdominal area is the priority action. Wilms tumor can rupture with pressure, which can lead to the spread of cancer cells. It is crucial to minimize handling of the tumor to prevent tumor spillage into the abdominal cavity.
Choice C reason: Scheduling the child for an abdominal ultrasound is a necessary diagnostic step, but it is not the immediate priority. The ultrasound will help in assessing the size and extent of the tumor, but the first action should be to ensure that the tumor is not disturbed.
Choice D reason: Obtaining a urine specimen for analysis is important for diagnosing the cause of the hematuria (blood in the urine), which is a common symptom of Wilms tumor. However, this is not the immediate priority compared to preventing potential harm to the child by avoiding pressure on the abdominal area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Hemorrhage is a potential issue for a child who has leukemia, as it is a condition that causes excessive bleeding, which can be caused by thrombocytopenia, coagulopathy, or bone marrow suppression. Leukemia can cause a low platelet count, which impairs the blood clotting process and increases the risk of bleeding from minor injuries, mucous membranes, or internal organs.
Choice B reason: Peripheral neuropathy is a potential issue for a child who has leukemia, as it is a condition that affects the nerves, which can be caused by chemotherapy, radiation, infection, or compression. Leukemia can cause nerve damage, which can result in numbness, tingling, pain, or weakness in the extremities, face, or trunk.
Choice C reason: Priapism is not a potential issue for a child who has leukemia, as it is a condition that causes a prolonged and painful erection of the penis, which can be caused by sickle cell disease, medication, trauma, or spinal cord injury. Leukemia does not affect the penis, but it can cause testicular pain, swelling, or masses due to leukemic infiltration.
Choice D reason: Tumor lysis syndrome is a potential issue for a child who has leukemia, as it is a condition that causes a rapid release of cellular contents into the bloodstream, which can be caused by chemotherapy, radiation, or spontaneous tumor breakdown. Tumor lysis syndrome can cause electrolyte imbalance, metabolic acidosis, renal failure, or cardiac arrhythmias.
Correct Answer is C
Explanation
Choice A reason: Ridged abdomen is not an expected finding for an infant who has pyloric stenosis, as it indicates abdominal rigidity or guarding, which can be a sign of peritonitis or bowel obstruction. Pyloric stenosis is a narrowing of the pyloric sphincter, which causes gastric outlet obstruction and delayed gastric emptying.
Choice B reason: Red currant jelly stools are not an expected finding for an infant who has pyloric stenosis, as they indicate blood and mucus in the stools, which can be a sign of intussusception or necrotizing enterocolitis. Pyloric stenosis does not affect the lower gastrointestinal tract, and the infant may have constipation or dehydration due to vomiting.
Choice C reason: Projectile vomiting is an expected finding for an infant who has pyloric stenosis, as it occurs after feeding due to the increased pressure in the stomach and the inability to pass food into the duodenum. Projectile vomiting can cause weight loss, dehydration, electrolyte imbalance, and metabolic alkalosis.
Choice D reason: Distended neck veins are not an expected finding for an infant who has pyloric stenosis, as they indicate increased central venous pressure, which can be a sign of heart failure or superior vena cava syndrome. Pyloric stenosis does not affect the cardiovascular system, and the infant may have sunken fontanels or poor skin turgor due to dehydration.
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.