When measuring a 6-month-old baby in the hospital for seizures, the nurse obtains a head circumference that is up 1 cm from the last measurement one week ago. The nurse re-measures and gets the same number What is the best next step?
Assume you made a mistake and report out the same head circumference as the before
Take Vital Signs
Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure
Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.
The Correct Answer is C
A. Assume you made a mistake and report out the same head circumference as before.
Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.
Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.
B. Take Vital Signs.
Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.
Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.
C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.
Correct Explanation: This is the best next step.
Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.
D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.
Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.
Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Always infantize the child
Incorrect Explanation: "Infantizing" a child with a growth hormone deficiency is not a relevant or appropriate approach.
Explanation: Growth hormone deficiency is a medical condition that affects a child's growth. Treating the child as an infant could potentially have negative psychological and social effects. It's important to provide appropriate support and understanding without treating the child differently due to their medical condition.
B. Monitor for leukemia
Incorrect Explanation: Monitoring for leukemia is not directly related to growth hormone deficiency.
Explanation: Growth hormone deficiency primarily affects a child's growth and development due to inadequate production of growth hormone. While there might be certain health concerns associated with the condition, monitoring for leukemia is not a common aspect of managing growth hormone deficiency.
C. Help the parents set realistic goals based on the child's age and abilities
Correct Explanation: This is an important aspect to include in teaching.
Explanation: When a child is diagnosed with growth hormone deficiency, it's crucial for parents to set realistic expectations regarding their child's growth. Growth hormone therapy can help, but it's essential to understand that the child's growth might still differ from their peers. Setting realistic goals based on the child's age and abilities can help manage expectations and provide appropriate support.
D. This illness is only seen in males
Incorrect Explanation: Growth hormone deficiency is not limited to males.
Explanation: Growth hormone deficiency can affect individuals of any gender. It is not exclusive to males. The condition results from insufficient production of growth hormone by the pituitary gland, and it can occur in both males and females.
Correct Answer is C
Explanation
A) "Limit fluid intake during mealtime":
Limiting fluid intake during meals is not a standard practice for managing type 1 diabetes. Proper hydration is important for overall health, and fluids should be consumed as needed.
B) "Notify the provider if blood glucose levels are over 350 milligrams/deciliter":
Blood glucose levels over 350 mg/dL can indicate hyperglycemia, which requires prompt attention. High blood glucose levels can lead to complications if not addressed promptly. Contacting the healthcare provider is an appropriate step. However, consistentBlood Glucose Levels Above 240 mg/dL (13.3 mmol/L) or presence of symptoms likefrequent urination, thirst, blurry vision, or fatigue) are concerning. The clientshould have contacted the health care provider by this point.
C) "Test the urine for ketones":
Testing urine for ketones is an important instruction. Ketones are produced when the body breaks down fat for energy, often in the absence of sufficient insulin. High ketone levels can indicate diabetic ketoacidosis (DKA), a serious complication. Regular ketone testing, especially during illness or high blood glucose levels, helps monitor for DKA.
D) "Withhold insulin dose if feeling nauseous":
This instruction is not accurate. Nausea could be a sign of various conditions, including illness. Insulin should not be withheld without consulting a healthcare provider. Managing insulin doses appropriately is crucial to maintaining blood glucose control
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