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 A
Explanation
The child with gastroesophageal reflux should avoid acidic and spicy foods, as well as high-fat and high- sugar foods. Sugar cookies are a low-fat and low-sugar snack, which indicates that the child understands the dietary restrictions. Choices B, C, and D are high in fat, sugar, or acid and may exacerbate gastroesophageal reflux symptoms.
Correct Answer is B
Explanation
Biliary atresia is a condition that can cause jaundice in newborns and infants, and it can also lead to tea-colored urine due to the presence of bilirubin in the urine. Infants with biliary atresia require further assessment and treatment, including possible surgery, to prevent liver damage and other complications.
A. Intussusception is a condition in which a part of the intestine folds into itself, causing an obstruction, but it does not typically present with jaundice or tea-colored urine.
C. Hirschsprung's disease is a congenital condition that affects the large intestine and can cause bowel obstruction, but it also does not typically present with jaundice or tea-colored urine.
D. Huntington's disease is a genetic neurological disorder that typically does not present in infants and does not cause jaundice or tea-colored urine.
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