A nurse is performing an annual wellness exam on an 8-year-old child whose last exam was one year ago. Which of the following findings should the nurse report to the provider?
Drinks 3 cups of 1% milk per day
Weight has increased by 5 kg (11 lb)
Height has increased by 3.8 cm (1.5 in)
Consumes three meals and two snacks per day
The Correct Answer is C
Rationale:
A. Drinks 3 cups of 1% milk per day: This intake is appropriate for an 8-year-old child. It supports bone development by providing sufficient calcium and vitamin D, aligning with dietary guidelines for school-age children.
B. Weight has increased by 5 kg (11 lb): A weight gain of about 2–3 kg (4.4–6.6 lb) per year is typical for children between ages 6 and 12. A 5 kg increase over one year is within normal limits and does not require provider notification unless accompanied by other concerns.
C. Height has increased by 3.8 cm (1.5 in): This is below the expected annual growth rate for an 8-year-old, which is typically 5 to 6.5 cm (2 to 2.5 in) per year. Slowed linear growth can indicate underlying medical or nutritional issues and should be reported for evaluation.
D. Consumes three meals and two snacks per day: This is a healthy and age-appropriate eating pattern for a school-age child, promoting stable energy levels and supporting growth and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Frequent swallowing: Frequent swallowing, especially of small amounts, can indicate that the child is swallowing blood from postoperative bleeding. This is a common early sign of hemorrhage following a tonsillectomy and requires immediate evaluation.
B. Increased drowsiness: Drowsiness can result from anesthesia, pain medication, or fatigue after surgery. While it should be monitored, it is not a specific indicator of postoperative hemorrhage in a child following tonsillectomy.
C. Elevated pain level: Pain is expected after tonsillectomy and does not necessarily signal bleeding. Sudden severe pain might warrant reassessment, but elevated pain alone is not a definitive sign of hemorrhage.
D. Diminished breath sounds: Diminished breath sounds are not typically associated with post-tonsillectomy hemorrhage. This finding may indicate a respiratory issue, but not specifically bleeding from the surgical site.
Correct Answer is D
Explanation
Rationale:
A. 42: A BMI of 42 falls in the category of class III (severe) obesity. This would only occur if the client's weight were significantly higher than 75 kg for a height of 1.8 m.
B. 28: A BMI of 28 indicates overweight status. At 75 kg and 1.8 m tall, the client does not meet the weight requirement for a BMI this high, as 28 would correspond to a weight closer to 91 kg.
C. 32: A BMI of 32 falls in the obesity range. For someone who is 1.8 m tall, a BMI of 32 would require a weight of about 104 kg, which is much higher than the client’s actual weight of 75 kg.
D. 24: The BMI is calculated as weight (kg) divided by height (m²). Using the formula:
BMI = 75 / (1.8 × 1.8) = 75 / 3.24 ≈ 23.15, which rounds to 24, placing the client in the normal weight range.
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