The mother of a 4-year-old client tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that their child is eating well and that their activity level is unchanged. The nurse, suspecting the possibility of Wilms tumor, should avoid which action during the physical assessment?
Monitoring the temperature for the presence of fever
Monitoring the blood pressure for the presence of hypertension
Assessing the urine for the presence of hematuria
Palpating the abdomen for a mass
The Correct Answer is D
Rationale:
A. Monitoring the temperature for fever is appropriate as part of a general assessment and could help identify signs of infection.
B. Monitoring blood pressure is important because hypertension can be associated with Wilms tumor.
C. Assessing the urine for hematuria is appropriate, as hematuria can be a symptom of Wilms tumor.
D. Palpating the abdomen is contraindicated in suspected Wilms tumor cases because it could cause the tumor to rupture, potentially spreading cancerous cells. Therefore, palpating the abdomen should be avoided until further diagnostic procedures are performed.
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Correct Answer is A
Explanation
Rationale:
A. Hemophilia is a bleeding disorder that affects the clotting process, and the partial thromboplastin time (PTT) is typically prolonged in individuals with hemophilia, indicating a deficiency in clotting factors.
B. Hemoglobin levels may remain normal unless the client experiences significant bleeding episodes.
C. Platelet count is usually normal in hemophilia, as the disorder affects clotting factors rather than platelet production.
D. Hematocrit levels may also remain normal unless there is significant bleeding, which would lower hematocrit due to blood loss.
Correct Answer is B
Explanation
Rationale:
A. Limiting caffeinated beverages is a good strategy as caffeine can increase urine production and contribute to enuresis.
B. Limiting fluid intake during the day is not recommended as it can lead to dehydration. Instead, fluids should be limited in the evening before bedtime.
C. Waking the child at scheduled intervals to void is a common behavioral strategy to help manage enuresis.
D. Anticholinergic medications may be prescribed if behavioral strategies are ineffective, indicating that the parents have received proper education on this potential intervention.