Which physical assessment technique will the nurse omit when caring for a 2-year-old child diagnosed with Wilms' tumor?

Percussing ankle and knee reflexes

Assessing for bowel sounds

Performing range-of-motion exercises on low extremities

Palpating the abdomen

Answer and Explanation

The Correct Answer is D

A. Percussing ankle and knee reflexes. Safe and non-invasive, and does not risk disturbing the tumor.
B. Assessing for bowel sounds. Routine part of assessment and does not involve manipulating the tumor.
C. Performing range-of-motion exercises on lower extremities. Safe and non-invasive, unrelated to the abdominal tumor.
D. Palpating the abdomen. Palpating the abdomen in a child with Wilms' tumor is avoided to prevent the risk of tumor rupture and subsequent metastasis.

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Correct Answer is C

Explanation

A. Test the urine for ketones. While testing for ketones can be part of illness management in diabetes, it is not as immediate an action as contacting a healthcare provider when blood glucose levels are very high.
B. Withhold insulin dose if feeling nauseous. Insulin should not be withheld due to nausea. It is important to maintain insulin to control blood glucose levels even when feeling unwell. Adjustments to insulin may be necessary based on blood glucose levels and food intake.
C. Notify the provider if blood glucose levels are over 350 mg/dL. Blood glucose levels over 350 mg/dL are concerning and may indicate the need for medical intervention to prevent complications like diabetic ketoacidosis. The healthcare provider should be notified.
D. Limit fluid intake during meal time. Adequate fluid intake is important, especially when blood glucose levels are high, to help prevent dehydration and facilitate glucose clearance. Limiting fluids is not appropriate.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.

Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.

Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.

Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.

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Which physical assessment technique will the nurse omit when caring for a 2-year-old child diagnosed with Wilms' tumor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is assisting in the care of a toddler. Exhibits A nurse is assisting in the care of a client. Complete the following sentence by using the list of options. The nurse should first address the child's dropdown followed by the child's dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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