A child is admitted with a suspected diagnosis of Wilms tumor. The nurse should place a sign with which of the following warnings over the child's bed?

Do not palpate abdomen

Contact precautions

Collect all urine

No venipuncture or blood pressure in left arm

Answer and Explanation

The Correct Answer is A

A. Do not palpate abdomen: Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. Palpation of the abdomen in a child with Wilms tumor can potentially rupture the tumor capsule and lead to dissemination of cancer cells or cause bleeding. Therefore, it is essential to instruct healthcare providers and caregivers not to palpate the child's abdomen to avoid complications.
B. Contact precautions: Contact precautions are not typically indicated for Wilms tumor. Contact precautions are implemented to prevent the transmission of infectious agents that are spread by direct or indirect contact with the client or their environment. Wilms tumor is not contagious and does not require contact precautions.
C. Collect all urine: While collecting urine may be necessary for diagnostic purposes and monitoring kidney function in a child with Wilms tumor, it is not the primary warning associated with the condition. The priority warning for Wilms tumor focuses on avoiding palpation of the abdomen to prevent potential complications.
D. No venipuncture or blood pressure in left arm: While venipuncture or blood pressure measurement in the left arm may be contraindicated in some situations, such as when a client has a central venous catheter or arteriovenous fistula, it is not specifically associated with Wilms tumor. The primary concern with Wilms tumor is to avoid palpation of the abdomen due to the risk of tumor rupture and dissemination of cancer cells.

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Correct Answer is D

Explanation

A. Battery involves the unauthorized or harmful touching of another person without their consent. Restraint without proper justification could potentially lead to a charge of battery, but the situation described does not involve actual physical contact.
B. Assault involves the threat of bodily harm to another person, creating fear or apprehension that the harm will be carried out. While the threat of restraint might cause fear, actual restraint is necessary to constitute assault.
C. Invasion of privacy refers to the unauthorized intrusion into an individual's private affairs or the public disclosure of private information. It does not apply to the act of physically restraining a client.
D. False imprisonment occurs when an individual is unlawfully restrained or confined against their will. In this scenario, the provider's directive to restrain the client against her wishes constitutes false imprisonment if the restraint is not justified by the client's medical condition or pose an immediate danger to herself or others.

A. Stop the enema and document that the client did not tolerate the procedure. B. Encourage the client to bear down C. Lower the height of the solution container D. Allow the client to expel some fluid before continuing

Correct Answer is C

Explanation

A. Stop the enema and document that the client did not tolerate the procedure:
This option may be appropriate if the client's discomfort is severe or if there are signs of distress. However, abdominal cramps are a common sensation during the administration of an enema, especially if the bowel is distended or constipated. Therefore, stopping the procedure may not be necessary at this point.
B. Encourage the client to bear down:
Bearing down might help the client expel the enema solution and relieve some discomfort. However, if the client is already experiencing abdominal cramps, bearing down could exacerbate the discomfort and is not likely to provide immediate relief.
C. Lower the height of the solution container:
This is the correct action to take. Lowering the height of the solution container reduces the flow rate of the enema solution, which can help alleviate abdominal cramps by slowing the rate of distension of the bowel. Slowing the infusion rate allows the client's colon to accommodate to the enema more comfortably.
D. Allow the client to expel some fluid before continuing:
Allowing the client to expel some fluid before continuing may provide some relief, but it does not directly address the cause of the discomfort. Lowering the height of the solution container is a more appropriate action to address the discomfort caused by abdominal cramps during the administration of the enema.

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A child is admitted with a suspected diagnosis of Wilms tumor. The nurse should place a sign with which of the following warnings over the child's bed?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is C

Explanation

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