The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff?
The cuff bladder covers 50% to 66% of the length of the upper arm.
The cuff is labeled "toddler.".
The cuff bladder width is approximately 40% of the circumference of the upper arm.
The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
The Correct Answer is A
The correct answer is choice A. The cuff bladder covers 50% to 66% of the length of the upper arm.
Choice A rationale:
Selecting a blood pressure cuff with a bladder that covers 50% to 66% of the length of the upper arm is the appropriate criterion for determining the cuff size for a 2-year-old boy. This range ensures accurate blood pressure measurement by ensuring a proper fit on the arm. If the cuff bladder is too small or too large, it can result in inaccurate readings.
Choice B rationale:
The label "toddler" on the cuff might be helpful in identifying the intended age group, but it doesn't provide precise measurements for cuff sizing. Relying solely on a label might not account for variations in arm sizes within the toddler age group.
Choice C rationale:
The cuff bladder width being 40% of the circumference of the upper arm might not be as accurate as the length-based criterion. A cuff that fits the arm's length is more critical in ensuring proper inflation and accurate blood pressure measurement.
Choice D rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm might result in an excessively large cuff for a 2-year-old, which can lead to inaccurate readings. Length-based sizing is more appropriate for accuracy in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Grasp the tick by the body to remove.
Choice A rationale:
Cleansing the wound with soap and water is a correct action. It helps to prevent infection after the tick has been removed.
Choice B rationale:
Grasping the tick by the body is incorrect. The proper method is to use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible and pull upward with steady, even pressure. Grasping the tick by the body can cause the mouth-parts to break off and remain in the skin, increasing the risk of infection.
Choice C rationale:
Leaving the tick in place and seeking emergency medical treatment is not recommended. The tick should be removed as soon as possible to reduce the risk of disease transmission.
Choice D rationale:
Avoiding touching the tick with bare hands is correct. Using gloves or tissue to handle the tick helps prevent the transmission of pathogens.
Correct Answer is D
Explanation
The correct answer is choice D: Sex can be presented as a normal part of growth and development.
Choice A rationale:
Children in 5th grade are generally around 10 to 11 years old, which means they are approaching puberty and experiencing physical changes. While it might be tempting to think that they are too young for sex education, it's important to acknowledge that they are at an age where their bodies are undergoing significant transformations. Providing them with age-appropriate sex education can empower them to understand these changes and navigate them safely.
Choice B rationale:
Correct terminology should not be reserved solely for older children. Using accurate and age-appropriate terminology when discussing topics related to sex and development is crucial. Children in 5th grade are capable of understanding basic anatomical terms and concepts, which can help them better comprehend their own bodies and the changes they are experiencing.
Choice C rationale:
Encouraging children to ask questions is an essential part of sex education. s reflect curiosity and a desire to learn. Discouraging questions can lead to misinformation and misunderstandings. Open dialogue about sex and development can help dispel myths and promote healthy attitudes toward these topics.
Choice D rationale:
Presenting sex as a normal part of growth and development is the foundation of comprehensive and age-appropriate sex education. Children in 5th grade are entering a stage of life where they might start experiencing sexual curiosity and have questions about their bodies. Addressing these questions in a respectful and factual manner can help them develop a healthy understanding of their own sexuality and promote safe behaviors.
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