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Which physical assessment technique will the nurse omit when caring for a 2-year-old child diagnosed with Wilms' tumor?

A.

Percussing ankle and knee reflexes

B.

Assessing for bowel sounds

C.

Performing range-of-motion exercises on low extremities

D.

Palpating the abdomen

Answer and Explanation

The Correct Answer is D

A. Percussing ankle and knee reflexes. Safe and non-invasive, and does not risk disturbing the tumor.
B. Assessing for bowel sounds. Routine part of assessment and does not involve manipulating the tumor.
C. Performing range-of-motion exercises on lower extremities. Safe and non-invasive, unrelated to the abdominal tumor.
D. Palpating the abdomen. Palpating the abdomen in a child with Wilms' tumor is avoided to prevent the risk of tumor rupture and subsequent metastasis.


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Related Questions

Correct Answer is C

Explanation

A. Keep edematous areas moist and covered. Keeping edematous areas moist and covered can worsen edema by trapping moisture and heat, leading to increased swelling.
B. Reach the child to minimize body movement. Minimizing body movement is not appropriate as it can lead to muscle weakness and stiffness. Encouraging gentle movement and position changes is beneficial.
C. Change the child's position frequently. Changing the child's position frequently helps prevent complications such as pressure ulcers and improves circulation, which can aid in reducing edema.
D. Keep the head of the child's bed flat. Elevating the head of the bed can help reduce edema by promoting venous return and reducing fluid accumulation in dependent areas.

Correct Answer is B

Explanation

A. "I expect the color of my urine to be amber." Ferrous sulfate does not typically affect the color of urine. This statement indicates a misunderstanding of the medication's effects.
B. "I will expect dark, tarry stools." Ferrous sulfate can cause stools to become dark or black, which is a common and expected side effect due to the iron content. This indicates the client understands a normal side effect of the medication.
C. "I will not get as many infections." Ferrous sulfate is used to treat iron deficiency anemia and does not directly influence the incidence of infections. This indicates a lack of understanding of the medication’s purpose.
D. "I will take extra care to protect against increased bruising." Increased bruising is not associated with ferrous sulfate. This indicates a misunderstanding of the medication's side effects.

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