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. 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.
Correct Answer is D
Explanation
A: This response indicates that the parents understand the need to manage the child's symptoms, which is important, but it does not directly relate to preventing the transmission of the disease to others.
B: Monitoring the child's temperature is a part of caring for someone with an illness, but like option A, it does not address the prevention of spreading the infection.
C: Ensuring the child stays hydrated is crucial when they are ill, especially with a throat infection, as it can help soothe the throat and keep the child comfortable. However, this practice is not specifically about preventing disease transmission.
D: This is the correct response that indicates an understanding of the teaching on preventing disease transmission. Streptococcal bacteria can contaminate toothbrushes, and using the same toothbrush after illness can lead to re-infection or spread the bacteria to others. Discarding the toothbrush after the infection can help prevent this.
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