A nurse is providing care to a 2-year-old who has a strong family history of hypertension. At the clinic visit, the child's caregiver asks when it would be appropriate to monitor blood pressure. Which of the following statements made by the nurse is accurate?
"Your child should have their blood pressure checked every time they are seen for a health care visit."
"Your child should have blood pressure screening annually, starting at 3 years of age."
"Your child should have blood pressure screenings every 6 months, starting at 2 years of age."
"Your child will not have blood pressure screening until they are in high school."
The Correct Answer is A
A. "Your child should have their blood pressure checked every time they are seen for a health care visit.": Children with a strong family history of hypertension are considered at increased risk, so regular monitoring at each health care visit allows for early detection and intervention if elevated blood pressure develops.
B. "Your child should have blood pressure screening annually, starting at 3 years of age.": Standard guidelines recommend routine annual screening starting at 3 years for children without risk factors, but those with a family history of hypertension require more frequent monitoring.
C. "Your child should have blood pressure screenings every 6 months, starting at 2 years of age.": While increased frequency may be considered in some high-risk children, standard recommendations prioritize checking at each visit rather than a fixed 6-month schedule.
D. "Your child will not have blood pressure screening until they are in high school.": Delaying screening until adolescence would miss opportunities for early identification and management of elevated blood pressure, particularly in children at risk due to family history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Toddlers with bleeding disorders should only receive one vaccine at a time due to the risk of bleeding at injection site: While spacing vaccines is not necessary solely for bleeding risk, precautions such as using smaller needles, applying firm pressure after injection, and choosing appropriate injection sites are recommended. Receiving multiple vaccines is generally safe.
B. Toddlers with von Willebrand disease should only receive vaccines available as nasal sprays to avoid bleeding from intramuscular injections: Nasal vaccines are limited in availability and type. Intramuscular vaccines can still be safely administered with proper technique and post-injection pressure, making this recommendation unnecessary and restrictive.
C. Toddlers with bleeding disorders are encouraged to stay up-to-date on vaccinations. The benefit of vaccinations outweighs the risk of bleeding: Maintaining the routine vaccination schedule protects children with bleeding disorders from serious infections. With proper precautions, the risk of bleeding at injection sites is minimal and manageable.
D. Toddlers with bleeding disorders should not receive any vaccinations, because the risk of bleeding outweighs the benefit of the vaccinations: Avoiding vaccines exposes the child to preventable infectious diseases. Careful technique and monitoring allow safe vaccination without withholding protection.
Correct Answer is B
Explanation
A. Assess the stoma site monthly to minimize disruption to the client's routine: Stoma assessment should be performed at least daily, especially in pediatric clients, to monitor for changes in color, size, and skin integrity, rather than monthly.
B. Consult the wound-ostomy team for guidance on treating irritated or broken skin around the stoma: Involving a wound-ostomy-continence (WOC) nurse ensures specialized care for peristomal skin breakdown and helps prevent complications, which is essential for maintaining the stoma and surrounding tissue.
C. Change the ostomy appliance daily regardless of the condition of the stoma site: Routine daily changes are unnecessary and can irritate the skin. Appliance changes should be based on the condition of the skin and the integrity of the pouch system.
D. Empty the ostomy's stool output only when the collection appliance is full to capacity: Waiting until the appliance is full can increase the risk of leakage, skin breakdown, and odor. It is recommended to empty the pouch when it is one-third to one-half full.
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