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 C
Explanation
In a 5-week-old infant presenting with a history of projectile vomiting after feedings, the nurse should expect to assess an olive-size mass in the epigastric area. This finding is consistent with pyloric stenosis, a condition in which the muscle at the bottom of the stomach that controls the flow of food into the small intestine becomes thickened and narrowed.
Rebound tenderness in the left lower abdominal quadrant, stool that consists of mucus and blood, and frequent burping accompanied by poor feeding are not typically associated with pyloric stenosis.
Correct Answer is B
Explanation
When moving an adolescent with scoliosis who is recovering after a surgical spinal instrumentation, the nurse should use the log roll technique. This technique involves keeping the spine in alignment while turning the client onto their side. Crossing the arms and legs, raising the hips, and flexing the knees are not appropriate techniques for moving a client with spinal instrumentation.
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