A nurse is assessing a 1-year-old toddler who notices a large abdominal mass and pink-tinged urine on the diaper. Which of the following disorders should the nurse suspect?
Nephritic syndrome
Wilms tumor
Pyloric stenosis
Intussusception
The Correct Answer is B
Choice A reason: Nephritic syndrome is a kidney disorder that causes inflammation and damage to the glomeruli, the filtering units of the kidneys. It can cause hematuria (blood in the urine), proteinuria (protein in the urine), hypertension (high blood pressure), and edema (swelling). However, it does not cause a palpable abdominal mass, which is a characteristic sign of Wilms tumor.
Choice B reason: Wilms tumor is a malignant tumor of the kidney that occurs mainly in children under 5 years of age. It can cause a large, firm, and painless abdominal mass, hematuria, abdominal pain, fever, and hypertension. It is the most common renal tumor in children and requires prompt diagnosis and treatment.
Choice C reason: Pyloric stenosis is a condition that causes narrowing of the pylorus, the outlet of the stomach. It can cause projectile vomiting, dehydration, weight loss, and a palpable olive-shaped mass in the upper abdomen. However, it does not cause hematuria or a large abdominal mass.
Choice D reason: Intussusception is a condition that occurs when a part of the intestine slides into another part, causing a blockage. It can cause abdominal pain, vomiting, bloody stools, and a sausage-shaped mass in the abdomen. However, it does not cause hematuria or a large abdominal mass.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Assessing the client's erythematous rash is an important action for the nurse to take, but it is not the priority. The rash is one of the minor criteria for diagnosing acute rheumatic fever, and it may not be present in all cases. The rash is usually non-pruritic and migratory, and it appears on the trunk and extremities.
Choice B reason: Identifying the degree of parental anxiety related to the diagnosis is an appropriate action for the nurse to take, but it is not the priority. The nurse should provide emotional support and education to the parents, and address their concerns and questions. However, this is not the most urgent action.
Choice C reason: Auscultating the rate and characteristics of the child's heart sounds is the priority action for the nurse to take, as it can detect the presence and severity of carditis, which is the most serious complication of acute rheumatic fever. Carditis is the inflammation of the heart muscle, valves, or pericardium, and it can cause murmurs, tachycardia, dysrhythmias, heart failure, or death.
Choice D reason: Using a pain-rating tool to determine the severity of the joint pain is an important action for the nurse to take, but it is not the priority. The joint pain is one of the major criteria for diagnosing acute rheumatic fever, and it is usually severe and migratory, affecting the large joints such as the knees, ankles, elbows, or wrists. The nurse should assess the pain level and provide analgesics and anti-inflammatory medications as prescribed.
Correct Answer is C
Explanation
Choice A reason: 60 beats per minute is too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice B reason: 80 beats per minute is also too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice C reason: 100 beats per minute is the lower limit of the normal range for a 6-month-old infant's apical heart rate. The nurse should withhold the dose of digoxin if the infant's apical heart rate is less than 100 beats per minute, as this can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice D reason: 120 beats per minute is within the normal range for a 6-month-old infant's apical heart rate. The nurse does not need to withhold the dose of digoxin if the infant's apical heart rate is 120 beats per minute, as this does not indicate digoxin toxicity. However, the nurse should still monitor the infant's heart rate, blood pressure, and digoxin level closely, as digoxin has a narrow therapeutic window and can cause adverse effects even at therapeutic doses.
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