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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because administering iron at bedtime can cause gastrointestinal upset and interfere with the child's sleep. Iron should be given between meals or one hour before meals for better absorption.
Choice B reason: This statement is correct because giving iron with orange juice or other foods rich in vitamin C can enhance iron absorption. Vitamin C helps convert iron into a form that is more easily absorbed by the body.
Choice C reason: This statement is incorrect because administering iron at mealtimes can reduce iron absorption. Iron can bind with certain substances in food, such as calcium, phytates, and tannins, and make it less available for the body.
Choice D reason: This statement is incorrect because giving iron with milk can decrease iron absorption. Milk contains calcium, which can interfere with iron absorption. Milk can also cause nausea and vomiting when taken with iron.
Correct Answer is B
Explanation
Choice A reason: Gastrointestinal system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as diarrhea, vomiting, or abdominal pain. These are not specific to Kawasaki disease and may be caused by other conditions.
Choice B reason: Cardiovascular system is the most important system to monitor in children with Kawasaki disease, as it can cause inflammation of the blood vessels, especially the coronary arteries that supply the heart. This can lead to serious complications such as coronary artery aneurysms, myocarditis, pericarditis, valvular dysfunction, and arrhythmias. Children with Kawasaki disease need regular echocardiograms to assess the cardiac function and structure.
Choice C reason: Respiratory system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as cough, rhinorrhea, or wheezing. These are not specific to Kawasaki disease and may be caused by other conditions.
Choice D reason: Integumentary system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as rash, peeling of the skin, red eyes, red lips, and red tongue. These are not specific to Kawasaki disease and may be caused by other conditions.
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