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
The nurse should implement the intervention of including the child's toy in the collection of information when the child screams and tries to hide behind the parent, dropping a stuffed toy. This can help engage the child and make them feel more comfortable during the medical history collection process. The other options (A, B, and C) are not appropriate interventions in this situation.
Correct Answer is A
Explanation
The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.
Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.
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