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.
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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 C
Explanation
A. This is a common symptom but bot a sign in children with otitis media. They may tug or pull at their ears due to discomfort or pain caused by the infection.
B. Manipulating the ear lobe can cause pain in children with otitis media because the infection often leads to inflammation and sensitivity in the ear area. This is, however, a symptom.
C. Erythema and edema are typical signs of inflammation, which can occur in the ear with otitis media.
D. While otitis media can cause some fluid buildup in the middle ear, clear drainage is not a common finding and may suggest another condition such as ear canal infection (otitis externa) or a perforated eardrum. Otitis media typically involves more purulent (pus-like) or cloudy fluid due to the infection.
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