The mother of a 4-year-old client tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that their child is eating well and that their activity level is unchanged. The nurse, suspecting the possibility of Wilms tumor, should avoid which action during the physical assessment?
Monitoring the temperature for the presence of fever
Monitoring the blood pressure for the presence of hypertension
Assessing the urine for the presence of hematuria
Palpating the abdomen for a mass
The Correct Answer is D
A. Monitoring the temperature for fever is appropriate as part of a general assessment and could help identify signs of infection.
B. Monitoring blood pressure is important because hypertension can be associated with Wilms tumor.
C. Assessing the urine for hematuria is appropriate, as hematuria can be a symptom of Wilms tumor.
D. Palpating the abdomen is contraindicated in suspected Wilms tumor cases because it could cause the tumor to rupture, potentially spreading cancerous cells. Therefore, palpating the abdomen should be avoided until further diagnostic procedures are performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assuming all Asians have the same culture is a generalization and may not accurately represent the specific cultural background of the family in question.
B. Hiring an interpreter may be helpful for language translation but may not provide insights into the nuances of the family's cultural beliefs and practices.
C. Directly engaging with the family and listening to their perspectives allows for a better understanding of their specific cultural beliefs and preferences.
D. While research can provide valuable information, direct communication with the family is essential for truly understanding their cultural needs and preferences.
Correct Answer is B
Explanation
A. Offering a pacifier is contraindicated after cleft lip and palate repair as it can disrupt the surgical site and interfere with healing.
B. Maintaining elbow restraints prevents the infant from touching or putting objects in their mouth, which could disrupt the surgical site and compromise healing.
C. The Trendelenburg position is not recommended as it can increase pressure on the surgical site and compromise breathing.
D. An ice collar may be used for pain relief in older children or adults but is not typically used in infants, and it may not be feasible in this population.
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