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","B","C","D"]
Explanation
These findings indicate that the child is experiencing significant pain, which is concerning, especially considering the history of sickle cell anemia and the recent increase in pain despite previous management with acetaminophen. Chest pain could also be indicative of a vaso-occlusive crisis or a respiratory complication.
Nasal flaring and moderate subcostal and substernal retractions are noted:
Nasal flaring and retractions suggest increased work of breathing, which could indicate respiratory distress. In a child with sickle cell anemia, respiratory complications like acute chest syndrome are a significant concern during a vaso-occlusive crisis.
Bilateral, moderate inspiratory and expiratory wheezes noted upon auscultation:
Wheezing indicates airway obstruction or inflammation, which could be due to asthma exacerbation, infection, or acute chest syndrome, all of which are common complications in children with sickle cell disease.
Correct Answer is B
Explanation
A. The calorie needs of toddlers vary depending on factors such as age, weight, height, activity level, and metabolism. 3,000 calories per day is likely to be excessive for most toddlers.
B. Although calorie intake is important for growth and development, the emphasis should be on the nutritional quality of the foods rather than solely on the quantity of calories consumed. Providing nutrient-rich foods ensures that the toddler receives essential vitamins, minerals, and other nutrients necessary for growth and development.
C. Vitamin supplementation may be necessary for some toddlers but it should be done under the guidance of a healthcare provider to ensure appropriate dosing and to avoid potential overdose or adverse effects.
D. An increased appetite alone does not guarantee adequate nutrition if the quality of the foods consumed is poor.
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