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. "I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me."
This response acknowledges the child's feelings and reassures the parents that bedwetting is a common occurrence, especially during hospitalization. It also demonstrates empathy by sharing a personal experience. However, it may not address the parents' concerns about their child's bedwetting or provide information on how to manage it.
B. "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better."
This response provides an explanation for the bedwetting incident, reassuring the parents that it is a common response to hospitalization and will likely resolve once the child feels better. It offers support and normalization of the behavior, which can help alleviate the parents' concerns.
C. "I will discuss your child's loss of bladder control with the provider."
This response indicates that the nurse will address the issue with the healthcare provider, which is appropriate if further evaluation or intervention is needed. However, it may not directly address the parents' concerns or provide immediate reassurance.
D. "Why is she wetting the bed in the hospital? She must wet the bed at home."
This response may come across as accusatory or judgmental, which can increase parental anxiety or guilt. It does not provide reassurance or support to the parents and does not address the child's immediate needs.
Correct Answer is A
Explanation
A. Place the child in a side-lying position.
This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs.
B. Restrain the child's arms.
Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure.
C. Elevate the child's legs on a pillow.
Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury.
D. Insert a padded tongue blade into the child's mouth.
Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.
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