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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

A. Apply lotion to hands and feet. B. Encourage the child to rest when possible. C. Place the child in a quiet environment. D. Make a list of foods that the child likes.

Correct Answer is C

Explanation

The nurse should instruct the mother to place the child in a quiet environment first. Kawasaki disease is an illness that can cause inﬂammation in the blood vessels and can lead to symptoms such as irritability and skin peeling. Placing the child in a quiet environment can help reduce stimulation and promote rest, which can help improve the child's symptoms. The other options (A, B, and D) may also be helpful, but placing the child in a quiet environment is a key intervention in this situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Correct Answer is A

Explanation

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

Correct Answer is C

Explanation

The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored. This child should receive follow- up assessment for what condition?

During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?

The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?

The nurse is caring for an adolescent with type 1 diabetes mellitus presenting with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the nurse take first?

When advising a new mother on caring for a child with croup, which symptom should be a priority concern for the telephone triage nurse?

The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?

The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?