For a child diagnosed with a Wilm's tumor. The nurse recognizes that which of the following is MOST important intervention when planning care for this child?
Avoiding further palpation of the abdomen
Obtaining an accurate height and weight
Monitoring vital signs
Assessing the urine for the presence of blood
The Correct Answer is A
A. Avoiding further palpation of the abdomen is crucial to prevent rupture of the tumor and potential spread of cancer cells.
B. Obtaining an accurate height and weight is important but not as critical as preventing tumor rupture.
C. Monitoring vital signs is essential but not the priority intervention in this context.
D. Assessing the urine for the presence of blood is important for overall assessment but not the most critical intervention compared to avoiding tumor rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While appropriate clothing is important, it is not the priority for reducing child abuse.
B. Skin and nail care are necessary for infant hygiene but are not directly related to preventing child abuse.
C. Recognizing that increased crying is normal during the first month and ensuring parents have emotional support can significantly reduce the risk of frustration that may lead to child abuse.
D. Understanding normal feeding patterns is important but less critical for the immediate goal of preventing child abuse.
Correct Answer is B
Explanation
A. This entry only provides vital signs and lacks context regarding the patient's activities or symptoms.
B. This entry is the most complete as it includes the time, activity (basketball practice), symptom (dizziness), absence of loss of consciousness, and relevant detail (no caffeine intake), giving a comprehensive picture of the patient's experience.
C. This entry describes the electrode placement but does not provide any information on activities or symptoms.
D. This entry details the patient's meals but does not include any information on activities or symptoms related to the Holter monitoring.
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