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 A
Explanation
A. Replacement therapy may require daily subcutaneous injections.
Explanation: Growth hormone deficiency (hypopituitarism) often requires treatment with growth hormone therapy. One common method of administering growth hormone is through daily subcutaneous injections. Subcutaneous injections involve injecting the medication under the skin into the fatty tissue. This is a routine part of growth hormone therapy, and nursing considerations would include educating the child and their family about proper injection techniques, site rotation, and adherence to the treatment schedule.
Explanation for the other choices:
B. Lifelong replacement therapy will be required:
This statement is generally true. Growth hormone deficiency often requires long-term treatment, which may extend throughout childhood and adolescence. However, in some cases, the need for growth hormone therapy might change based on the individual's response to treatment and growth patterns.
C. Treatment is most successful if started during adolescence:
The optimal timing for starting growth hormone therapy can vary depending on the specific circumstances and the underlying cause of growth hormone deficiency. While treatment during adolescence can be effective, growth hormone therapy can also be successful if started earlier in childhood or later in adolescence. The key is identifying and treating the deficiency as soon as possible to promote healthy growth.
D. Treatment is considered successful if children attain full stature by adulthood:
While growth hormone therapy aims to support growth, achieving "full stature" might not always be possible. The goal of treatment is to help the child reach a more typical height based on their genetic potential and individual response to therapy. The success of treatment is determined by improvements in growth velocity and height, rather than necessarily achieving "full stature," which can vary greatly among individuals.
Correct Answer is D
Explanation
A) "I can store unopened bottles of insulin in the freezer."
This statement is incorrect. Insulin should not be stored in the freezer. Insulin should be stored in the refrigerator, and the currently used vial can be kept at room temperature for up to 28 days to avoid the discomfort of injecting cold insulin.
B) "I should not take my regular insulin when I am sick."
This statement is incorrect. When a person with type 1 diabetes is sick, it's important to continue taking insulin. In fact, during illness, blood sugar levels can become more difficult to manage, and insulin may be needed in adjusted doses. Skipping insulin during sickness can lead to uncontrolled blood sugar levels and potentially worsen the illness.
C) "My morning blood glucose should be between 90 and 130."
This statement is a good range to aim for in terms of fasting blood glucose levels, but it's not an indication of understanding the teaching about diabetes management as a whole. While this knowledge is important, the statement about eating a snack before playing soccer directly reflects understanding of how to manage blood sugar during physical activity.
"D) I should eat a snack half an hour before playing soccer."
Explanation:
Managing blood sugar levels is crucial for individuals with type 1 diabetes, especially when engaging in physical activities like playing soccer. Eating a snack before playing helps prevent hypoglycemia (low blood sugar) during exercise. Physical activity can cause the body to use up glucose faster, potentially leading to low blood sugar levels, and having a snack before exercise can help maintain stable blood sugar levels.
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