During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?
Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks.
Measure the child's blood pressure three times during the visit and determine the highest of the readings.
Conduct a head-to-toe assessment and omit repeated blood pressures during the examination.
Take the blood pressure two more times during the visit and determine the average of the three readings.
The Correct Answer is D
If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks
A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings
B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination
C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hypoparathyroidism is a disorder in which the parathyroid glands produce insufficient amounts of parathyroid hormone, which regulates calcium and phosphorus levels in the body. In hypoparathyroidism, there is a decreased level of calcium in the blood, which can result in carpal spasm or tetany when pressure is applied to the upper arm.
Therefore, the nurse should review the child's calcium level (D) to determine if it is within the normal range. Low calcium levels can cause muscle spasms, seizures, and cardiac arrhythmias. Hypocalcemia may also result in other symptoms such as numbness, tingling, and muscle cramps.
Potassium (A), chloride (B), and sodium (C) are electrolytes that play important roles in various physiological processes in the body, but they are not directly related to the development of carpal spasm in a child with hypoparathyroidism. While hypokalemia (low potassium) or hyponatremia (low sodium) can cause muscle weakness or cramps, these conditions are not typically associated with carpal spasm in hypoparathyroidism.
Correct Answer is D
Explanation
Aortic stenosis is a narrowing of the aortic valve, which can cause decreased blood flow from the left ventricle to the systemic circulation. In infants with aortic stenosis, the left ventricle must work harder to pump blood through the narrowed valve, which can lead to left ventricular hypertrophy, heart failure, and pulmonary edema. Bilateral fine crackles in both lung fields may indicate fluid overload in the lungs, which is a common complication of heart failure. Hypotension and tachycardia may also be present due to decreased cardiac output.
Option A is not a typical finding associated with aortic stenosis.
Option B is not directly related to the infant's cardiac condition.
Option C is not a typical finding associated with heart failure.
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