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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bleeding: While haloperidol can rarely cause agranulocytosis, which may lead to bleeding, it is not a common adverse effect associated with the medication. However, clients taking antipsychotic medications like haloperidol should be monitored for any signs of bleeding, such as petechiae or bruising.
B. Cataracts: Haloperidol is not typically associated with the development of cataracts. However, long-term use of certain antipsychotic medications, including haloperidol, may increase the risk of developing metabolic side effects such as weight gain and dyslipidemia, which could indirectly contribute to the risk of cataract formation.
C. Dysrhythmias: This is the correct answer. Haloperidol has the potential to prolong the QT interval, leading to a type of dysrhythmia known as torsade’s de pointes. Therefore, clients taking haloperidol should be monitored for signs of QT prolongation, such as palpitations, syncope, or sudden cardiac arrest.
D. Pancreatitis: While rare, haloperidol has been associated with pancreatitis as a potential adverse effect. However, dysrhythmias are a more common and immediate concern, especially with acute administration or in clients with predisposing factors for QT prolongation, such as electrolyte imbalances or concurrent use of other medications known to prolong the QT interval.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
