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. Remove clothing. Removing clothing is important to prevent further injury from retained heat or chemicals, but it is not the first priority compared to ensuring a patent airway and adequate breathing.
B. Administer pain medication. Pain management is important but comes after ensuring the child's airway and respiratory status are stable.
C. Assess respiratory status. Burns on the face and chest can compromise the airway and breathing. Assessing respiratory status is the first priority to ensure the child’s airway is not obstructed and that they are receiving adequate oxygen.
D. Insert a Foley catheter. Inserting a Foley catheter may be necessary to monitor urine output and assess kidney function in severe burns, but it is not the first priority compared to assessing respiratory status.

A. "I'm tired and want to take a nap." B. "I am scared and I want to go home C. "I am hungry and thirsty." D. "My belly doesn't hurt anymore."

Correct Answer is D

Explanation

A. "I'm tired and want to take a nap." Common in sick children and not necessarily concerning in this context.
B. "I am scared and I want to go home." Emotional response, typical in children facing surgery.
C. "I am hungry and thirsty." Normal sensations and not indicative of the severity of the condition.
D. "My belly doesn't hurt anymore." This statement suggests potential rupture or perforation of the appendix, which can lead to peritonitis and is a surgical emergency. A sudden relief of pain can indicate a worsening condition rather than improvement.

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

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Naxlex Comprehensive Predictor Exams

A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Correct Answer is C

Explanation

A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?

Correct Answer is D

Explanation

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