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When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most important to avoid which of the following?
- A. Measuring the child's chest circumference
- B. Palpating the child's abdomen
- C. Measuring the child's occipitofrontal circumference
- D. Placing the child in an upright position
Correct Answer: B
Rationale: Measuring the child's chest circumference: Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen. Palpating the child's abdomen: This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor. Measuring the child's occipitofrontal circumference: This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor. Placing the child in an upright position: Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.
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A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Hematuria
- B. Urinary frequency
- C. Polyuria
- D. Dependent edema
- E. Dysuria
Correct Answer: A,B,E
Rationale: A. Hematuria: Hematuria, or blood in the urine, is a common finding in urinary tract infections (UTIs). It occurs due to irritation and inflammation of the urinary tract lining, causing small blood vessels to leak blood into the urine. B. Urinary frequency: Urinary frequency, or the need to urinate more often than usual, is a classic symptom of a UTI. It occurs because the infection irritates the bladder lining, leading to a frequent urge to urinate even when the bladder is not full. C. Polyuria: Polyuria, or excessive urination, is not typically associated with uncomplicated urinary tract infections. Instead, UTIs usually cause urinary frequency without necessarily increasing the total volume of urine produced (polyuria). D. Dependent edema: Dependent edema, or swelling in the lower extremities due to fluid accumulation, is not a typical finding in urinary tract infections. UTIs primarily affect the urinary system and do not typically cause system
A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?
- A. My belly doesn't hurt anymore.
- B. I am hungry and thirsty.
- C. I'm tired and want to take a nap.
- D. I am scared and I want to go home.
Correct Answer: A
Rationale: My belly doesn't hurt anymore.' - This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Place the child in a side-lying position.
- B. Restrain the child's arms.
- C. Elevate the child's legs on a pillow.
- D. Insert a padded tongue blade into the child's mouth.
Correct Answer: A
Rationale: Place the child in a side-lying position. This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs. Restrain the child's arms. Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure. Elevate the child's legs on a pillow. Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury. Insert a padded tongue blade into the child's mouth. Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.
An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?
- A. No treatment is necessary, the fluid is reabsorbing normally
- B. Keeping the infant in a flat, supine position until the fluid is gone
- C. Referral to a surgeon for repair
- D. Massaging the groin area twice a day until the fluid is gone.
Correct Answer: A
Rationale: No treatment is necessary, the fluid is reabsorbing normally: - This option suggests that the hydrocele is resolving spontaneously, which is often the case in infants. The physician may choose to observe the hydrocele over time as it is likely to resolve without intervention. Keeping the infant in a flat, supine position until the fluid is gone: - This option does not address the underlying cause of the hydrocele and is not a standard treatment recommendation. Additionally, positioning changes are unlikely to affect the resolution of the hydrocele. Referral to a surgeon for repair: - Surgical repair may be considered if the hydrocele persists beyond a certain age or if it causes discomfort or complications. However, it is typically not recommended in infants unless the hydrocele persists beyond infancy or causes other issues. Massaging the groin area twice a day until the fluid is gone: - Massaging the groin area is not a recommended treatment for hydrocele and may not be effective in resolving the condition. Additionally, manipulating the scrotum may cause discomfort or injury to the infant.
A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child?
- A. Broth
- B. Apple juice
- C. Cherry gelatin
- D. Pedialyte
Correct Answer: D
Rationale: Broth: Broth is not typically recommended for children with acute diarrhea because it lacks the necessary electrolytes to adequately replace those lost through diarrhea. While it can help provide some fluids, it may not be sufficient for rehydration and could potentially worsen dehydration if electrolytes are not adequately replaced. Apple juice: While apple juice may seem like a hydrating option, it is not the best choice for children with acute diarrhea. Apple juice contains a high amount of sugar, which can draw water into the intestines and worsen diarrhea. Additionally, it lacks the necessary electrolytes needed for rehydration. Cherry gelatin: Cherry gelatin is not recommended for rehydrating a child with acute diarrhea. Like apple juice, it contains sugar, which can exacerbate diarrhea by drawing water into the intestines. Gelatin also lacks the electrolytes needed to replace those lost through diarrhea. Pedialyte: Pedialyte is the preferred choice for rehydrating a child with acute diarrhea. It is specifically formulated to replace lost fluids and electrolytes and is less likely to worsen diarrhea compared to sugary beverages like juice or gelatin. Pedialyte helps prevent dehydration by providing a balanced mixture of water, sugar, and electrolytes, making it an effective choice for managing diarrhea in children.