A nurse is caring for a toddler whose parent states that while bathing the child, she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?
Determine if the child is having pain.
Instruct the parent to avoid pressing on the abdominal area.
Schedule the child for an abdominal ultrasound.
Obtain a urine specimen for analysis.
The Correct Answer is B
The correct answer is: B
Choice A reason: Determining if the child is having pain is important, but it is not the immediate priority. Pain assessment will help in managing the child’s comfort and can provide additional information about the condition. However, in the case of Wilms tumor, which is a common kidney cancer in children, the priority is to prevent any action that could potentially cause tumor spillage or spread.
Choice B reason: Instructing the parent to avoid pressing on the abdominal area is the priority action. Wilms tumor can rupture with pressure, which can lead to the spread of cancer cells. It is crucial to minimize handling of the tumor to prevent tumor spillage into the abdominal cavity.
Choice C reason: Scheduling the child for an abdominal ultrasound is a necessary diagnostic step, but it is not the immediate priority. The ultrasound will help in assessing the size and extent of the tumor, but the first action should be to ensure that the tumor is not disturbed.
Choice D reason: Obtaining a urine specimen for analysis is important for diagnosing the cause of the hematuria (blood in the urine), which is a common symptom of Wilms tumor. However, this is not the immediate priority compared to preventing potential harm to the child by avoiding pressure on the abdominal area.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Pyloric stenosis is not a manifestation of inadequate motility of part of the intestine, but rather a hypertrophy of the pyloric muscle, which causes gastric outlet obstruction and delayed gastric emptying. Pyloric stenosis typically presents with projectile vomiting, dehydration, weight loss, and a palpable olive-shaped mass in the abdomen.
Choice B reason: Hirschsprung's disease is a manifestation of inadequate motility of part of the intestine, as it is caused by the absence of ganglion cells in the distal colon, which results in a lack of peristalsis and a functional obstruction. Hirschsprung's disease typically presents with constipation, abdominal distension, failure to thrive, and enterocolitis.
Choice C reason: Encopresis is not a manifestation of inadequate motility of part of the intestine, but rather a condition in which a child over 4 years of age involuntarily passes stool, usually due to chronic constipation and fecal impaction. Encopresis typically presents with soiling of the underwear, abdominal pain, low self-esteem, and behavioral problems.
Choice D reason: Enterocolitis is not a manifestation of inadequate motility of part of the intestine, but rather an inflammation of the mucosa of the small and large intestines, which can be caused by various infections, allergies, or ischemia. Enterocolitis typically presents with diarrhea, fever, abdominal pain, and dehydration.
Correct Answer is D
Explanation
Choice A reason: Offering the client a reward for agreeing to the treatment is not an appropriate action, as it does not respect the client's autonomy and may be seen as coercive or manipulative.
Choice B reason: Notifying the provider of the client's refusal and documenting it in the chart is a necessary action, but not the first one. The nurse should first attempt to educate the client and the parent and address their concerns and preferences.
Choice C reason: Initiating the treatment as per the parent's request and the provider's order is not an appropriate action, as it violates the client's right to informed consent and may cause harm or resentment.
Choice D reason: Educating the client and the parent about the benefits and risks of the treatment is the best action, as it provides them with the information they need to make an informed decision and shows respect for their values and beliefs.
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