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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Thick yellow crusted lesion on a red base are characteristic of impetigo.
B. Pediculosis capitis (head lice infestation) presents with itching and scratching of the head due to the allergic reaction to the saliva of the lice. While other conditions may present with similar symptoms, itching and scratching are classic signs of head lice infestation.
C. Firmly attached white particles on the hair are indicative of nits (lice eggs).
D. Patchy areas of hair loss may be seen in conditions like alopecia areata or fungal infections but are not specific to pediculosis capitis.
Correct Answer is D
Explanation
A. Ibuprofen is not associated with Reye syndrome. It is a non-steroidal anti-inflammatory drug (NSAID) often used to relieve pain and reduce fever in children.
B. Grapefruit juice does not increase the risk of Reye syndrome. However, it can interact with various medications, altering their effectiveness.
C. Using a humidifier can help ease symptoms of influenza by keeping the air moist, and it does not increase the risk of Reye syndrome.
D. This statement indicates an increased risk for Reye syndrome. Aspirin, or salicylate-containing medications, should be avoided in children and teenagers recovering from viral infections like influenza due to the associated risk of Reye syndrome.
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