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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
Choice B rationale:
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
Choice C rationale:
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
Choice D rationale:
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
Choice E rationale:
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.
Correct Answer is C
Explanation
The correct answer is choice C. Sparse hair.
Choice A rationale:
Sleepiness is not a typical symptom of hypothyroidism. Hypothyroidism, a condition where the thyroid gland doesn't produce enough thyroid hormone, leads to a slower metabolism which can cause fatigue, but not necessarily sleepiness.
Choice B rationale:
Weight loss is not associated with hypothyroidism. In fact, weight gain is a common symptom due to the reduced metabolic rate caused by insufficient thyroid hormone levels.
Choice C rationale:
Sparse hair is a characteristic symptom of hypothyroidism. The thyroid hormones play a crucial role in the growth and maintenance of hair follicles. In hypothyroidism, hair can become brittle, thin, and sparse.
Choice D rationale:
Diarrhea is not a typical symptom of hypothyroidism. Constipation, on the other hand, is more commonly associated with this condition due to the slowed digestive processes caused by low thyroid hormone levels.
Choice E rationale:
Puffiness around the eyes is not typically associated with hypothyroidism. However, it is a symptom of another thyroid disorder known as Graves' disease, which is characterized by hyperthyroidism (overactive thyroid).
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