The parents state that he has not voided in several hours. Inspection of the penis reveals edema, redness, and the foreskin is behind the glans penis. Based on this assessment, what would the nurse anticipate as the priority action?
Perform an ultrasound to determine if there is urinary retention.
Ask the parents specifically how long the infant has not voided.
Alert the ER physician to the patient’s condition.
Continue to monitor the patient in the ER setting.
The Correct Answer is C
Choice A reason:
Performing an ultrasound to determine if there is urinary retention is not the immediate priority action. While an ultrasound can help assess urinary retention, the presence of edema, redness, and the foreskin being behind the glans penis suggests a condition known as paraphimosis. Paraphimosis is a medical emergency that requires prompt attention to prevent complications such as tissue damage. Therefore, alerting the ER physician is the priority action.
Choice B reason:
Asking the parents specifically how long the infant has not voided is important for gathering information, but it is not the immediate priority action. The clinical signs of edema, redness, and the foreskin being behind the glans penis indicate a potential emergency that requires immediate medical intervention. While obtaining a detailed history is important, the nurse should first alert the ER physician to ensure timely management.
Choice C reason:
Alerting the ER physician to the patient’s condition is the correct priority action. The presence of edema, redness, and the foreskin being behind the glans penis suggests paraphimosis, which is a urological emergency. Prompt intervention is necessary to reduce the foreskin and restore normal blood flow to prevent tissue damage3. The ER physician can provide the necessary treatment and management for this condition.
Choice D reason:
Continuing to monitor the patient in the ER setting is not appropriate without first addressing the potential emergency. The signs of edema, redness, and the foreskin being behind the glans penis indicate a condition that requires immediate medical attention. Monitoring alone is insufficient; the nurse must alert the ER physician to ensure prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. An excessive destruction of platelets.
Choice A: Diffuse fibrin deposition in the microvasculature
Diffuse fibrin deposition in the microvasculature is not characteristic of immune thrombocytopenia (ITP). This description is more aligned with disseminated intravascular coagulation (DIC), a condition where widespread clotting occurs within the blood vessels, leading to multiple organ damage.
Choice B: Deficiency in the production rate of globin chains
A deficiency in the production rate of globin chains is associated with thalassemia, a genetic blood disorder that affects the production of hemoglobin. This is not related to the pathology of immune thrombocytopenia.
Choice C: An excessive destruction of platelets
An excessive destruction of platelets is the hallmark of immune thrombocytopenia (ITP). In ITP, the immune system mistakenly targets and destroys platelets, which are essential for blood clotting. This leads to a low platelet count and an increased risk of bleeding.
Choice D: Bone marrow failure in which all elements are suppressed
Bone marrow failure in which all elements are suppressed is characteristic of aplastic anemia, a condition where the bone marrow fails to produce sufficient blood cells. This is not related to immune thrombocytopenia.
Correct Answer is C
Explanation
Choice A reason:
Walnuts are a source of protein and contain phenylalanine, an amino acid that individuals with phenylketonuria (PKU) must limit in their diet. While nuts can be a healthy snack for most people, they are not suitable for those with PKU due to their high phenylalanine content. Therefore, walnuts are not the best choice for children with PKU.
Choice B reason:
Cow’s milk is another source of protein and contains significant amounts of phenylalanine. Dairy products, including milk, cheese, and yogurt, are generally high in protein and should be avoided by individuals with PKU. Consuming cow’s milk can lead to elevated levels of phenylalanine in the blood, which can be harmful to children with PKU.
Choice C reason:
Bananas are a fruit that contains very low levels of phenylalanine. Fruits and vegetables are generally safe for individuals with PKU as they are low in protein and phenylalanine. Bananas, in particular, are a good option for children with PKU as they provide essential nutrients without contributing to high phenylalanine levels.
Choice D reason:
Diet soda with aspartame should be avoided by individuals with PKU because aspartame is an artificial sweetener that contains phenylalanine. Consuming products with aspartame can lead to an increase in phenylalanine levels in the blood, which can be harmful to those with PKU. Therefore, diet soda with aspartame is not a suitable choice for children with PKU.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.