When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most important to avoid which of the following?
Measuring the child's chest circumference
Palpating the child's abdomen
Measuring the child's occipitofrontal circumference
Placing the child in an upright position
The Correct Answer is B
A. Measuring the child's chest circumference:
Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen.
B. Palpating the child's abdomen:
This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor.
C. Measuring the child's occipitofrontal circumference:
This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor.
D. Placing the child in an upright position:
Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Maintain a saline-lock:
While maintaining a saline lock is important for ensuring vascular access in case of emergency, it is not the priority action in caring for a child with acute glomerulonephritis. Monitoring fluid balance and electrolyte levels may be necessary, but the immediate priority is to educate the parents about potential complications.
B. Check the child's weight daily:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
Dietary modifications, including reducing salt intake, may be recommended for managing acute glomerulonephritis. However, it is not the priority action at this stage.
D. Educate the parents about potential complications:
Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
Correct Answer is B
Explanation
A. Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection.
B. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures.
C. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique.
D. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
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