A nurse is caring for a toddler whose parent states 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.
Obtain a urine specimen for a urinalysis.
Instruct the parent to avoid pressing on the abdominal area.
Schedule the child for an abdominal ultrasound.
The Correct Answer is C
A. While assessing for pain is important, it is not the priority in this situation. The presence of pink- colored urine and a palpable mass in the abdominal area are more concerning findings that warrant immediate investigation.
B. 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.
C. 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.
D. The decision to schedule additional diagnostic tests, such as an abdominal ultrasound, can be made based on the results of the urinalysis and further clinical assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Scoliosis is a lateral curvature of the spine, which is characterized by an abnormal sideways curvature of the spine. Scoliosis may be idiopathic (of unknown cause) or secondary to other conditions.
B. Kyphosis is an excessive outward curvature of the spine, causing a rounded or hunched back. It is commonly associated with poor posture or structural abnormalities of the spine
C. Torticollis (wry neck) is characterized by a twisted or tilted neck posture due to muscle spasm or congenital muscular torticollis.
D. Lordosis is an excessive inward curvature of the spine, commonly observed in the lumbar (lower back) or cervical (neck) regions. It may occur as a normal variant or be associated with conditions such as muscle imbalances.
Correct Answer is A
Explanation
A. A needleless syringe and a doll allow the child to role-play the experience of receiving an injection, which can help in understanding and coping with the procedure. It's a form of play therapy that can be particularly beneficial for children with medical conditions, as it helps them to process their experiences in a safe and controlled environment.
B. Reading a story about another child with diabetes can provide comfort and a sense of relatability. It can also serve as an educational tool, helping the child to understand their condition and the importance of treatments like insulin injections.
C. While not directly related to diabetes or injections, playing a video game can be a good distraction technique. It can help the child to relax and take their mind off the distress associated with injections. However, it may not have the same therapeutic benefits in terms of processing the experience as the other options listed.
D. Free play in a playroom offers a variety of benefits, including the opportunity for the child to express themselves creatively, engage with others, and momentarily escape from the stress of medical treatments. It's a form of expressive therapy that can improve mood and reduce anxiety.
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