A nurse is caring for a toddler whose parent states 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.

Obtain a urine specimen for a urinalysis.

Instruct the parent to avoid pressing on the abdominal area.

Schedule the child for an abdominal ultrasound.

Answer and Explanation

The Correct Answer is C

A. While assessing for pain is important, it is not the priority in this situation. The presence of pink- colored urine and a palpable mass in the abdominal area are more concerning findings that warrant immediate investigation.

B. 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.

C. 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.

D. The decision to schedule additional diagnostic tests, such as an abdominal ultrasound, can be made based on the results of the urinalysis and further clinical assessment.

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Correct Answer is B

Explanation

A. Admitting the client is necessary to prevent the spread of infection and provide a controlled environment for the child.
B. Measuring the head circumference is not typically necessary for bacterial meningitis as the sutures are closed raised intracranial pressure does not affect circumference.
C. Seizures can be a complication of bacterial meningitis, so this intervention is important to ensure the child's safety.
D. The semi-Fowler’s position helps to decrease ICP and facilitate breathing, which is crucial in the care of a child with bacterial meningitis.

A. Facial edema B. Hypertension C. Smokey brown urine D. Polyuria

Correct Answer is A

Explanation

Nephrotic syndrome is a renal condition characterized by increased permeability of the glomerular filtration barrier, leading to excessive protein loss in the urine. Cardinal features include : (proteinuria), hypoalbuminemia, edema, and hyperlipidemia.

B. Hypertension: While hypertension can occur in some cases of nephrotic syndrome, it is not a consistent finding.
C. Smokey brown urine: Smokey brown urine can be a sign of rhabdomyolysis or hemolysis, not nephrotic syndrome. In nephrotic syndrome, urine may appear foamy due to proteinuria
D. Polyuria: Polyuria is not a typical finding in nephrotic syndrome. Nephrotic syndrome is more commonly associated with oliguria (decreased urine output) due to decreased blood volume and activation of the renin-angiotensin-aldosterone system.

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A nurse is caring for a toddler whose parent states 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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