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 ["C","D"]
Explanation
The correct answers are choices C. Novolin R, and D. NovoLog.
Choice A rationale:
Novolin N is an intermediate-acting insulin, not rapid or short acting. It has a slower onset and longer duration of action, making it unsuitable for rapid blood sugar control.
Choice B rationale:
Lantus is a long-acting insulin that provides basal insulin coverage and has a relatively steady effect over 24 hours. It is not rapid or short acting and is used to provide a baseline level of insulin, not for immediate blood sugar control.
Choice C rationale:
Novolin R, also known as regular insulin, is a short-acting insulin with an onset of about 30 minutes and a peak effect around 2 to 3 hours. It is often used to cover mealtime blood sugar elevations and is suitable for short-term blood sugar control.
Choice D rationale:
NovoLog is a rapid-acting insulin analog with an onset of about 15 minutes and a peak effect within 1 to 2 hours. It is designed to mimic the body's rapid insulin release after meals, making it effective for controlling postprandial blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale:
A goiter refers to the enlargement or hypertrophy of the thyroid gland. This can occur due to various reasons, such as iodine deficiency, autoimmune disorders like Hashimoto's thyroiditis, or Graves' disease (which is associated with hyperthyroidism). The thyroid gland produces hormones that regulate metabolism and growth, and when it becomes enlarged, it can lead to visible swelling in the neck.
Choice B rationale:
The posterior pituitary gland is responsible for the release of hormones like vasopressin (antidiuretic hormone) and oxytocin. A goiter is not associated with the posterior pituitary gland. Issues with the posterior pituitary can lead to problems with water balance and uterine contractions, but not thyroid enlargement.
Choice C rationale:
The adrenal glands are responsible for producing hormones like cortisol and adrenaline. While adrenal disorders can lead to various hormonal imbalances, a goiter is not related to adrenal gland function. Adrenal issues might cause symptoms like fatigue, weight changes, and blood pressure irregularities.
Choice D rationale:
The anterior pituitary gland produces hormones that regulate the functions of other endocrine glands, including the thyroid gland. However, a goiter is not directly associated with the anterior pituitary. The anterior pituitary's malfunction can result in disorders like growth hormone deficiency or Cushing's disease, but not thyroid enlargement.
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