During a routine clinic visit, a nurse finds that a 5-year-old girl’s systolic blood pressure is above the 90th percentile. What should be the nurse’s subsequent action?

Refer the child to the healthcare provider and schedule a blood pressure evaluation in two weeks.

Perform a comprehensive assessment and avoid repeated blood pressure measurements during the examination.

Take the child’s blood pressure three times during the visit and record the highest reading.

Measure the blood pressure twice more during the visit and calculate the average of the three readings.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Measure the blood pressure twice more during the visit and calculate the average of the three readings.

Choice A rationale:

Referring the child to the healthcare provider and scheduling a blood pressure evaluation in two weeks is not the immediate next step. It is important to confirm the elevated blood pressure reading during the same visit before making any referrals.

Choice B rationale:

Performing a comprehensive assessment and avoiding repeated blood pressure measurements is not appropriate. Repeated measurements are necessary to confirm the initial finding of elevated blood pressure.

Choice C rationale:

Taking the child’s blood pressure three times and recording the highest reading is not the best practice. The highest reading might not be representative of the child’s true blood pressure.

Choice D rationale:

Measuring the blood pressure twice more during the visit and calculating the average of the three readings is the correct approach. This method helps to ensure that the blood pressure reading is accurate and not influenced by temporary factors such as anxiety or movement.

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Correct Answer is D

Explanation

Choice A rationale
Flexing the knees is not the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. While it may provide some comfort, it does not provide the necessary support to the spine that is needed during movement.
Choice B rationale
Raising the hips is not the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. This action could potentially cause strain or damage to the surgical site.
Choice C rationale
Crossing the arms and legs is not the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. This action does not provide the necessary support to the spine during movement.
Choice D rationale
Performing a log roll is the recommended technique when moving a client who is recovering from surgical spinal instrumentation for scoliosis. This technique involves the patient keeping their body in alignment while turning onto their side. It helps to maintain the integrity of the spinal fusion and prevent injury to the surgical site.

A. Advise the client about the risks and benefits associated with oral contraceptives. B. Inform the client about how to obtain a variety of free oral contraceptives from the clinic. C. Encourage the client to discuss her contraceptive needs with her parents. D. Explain that parental consent is required to receive contraceptives.

Correct Answer is A

Explanation

Choice A rationale
It’s important to educate the adolescent about the risks and benefits associated with oral contraceptives. This includes potential side effects, effectiveness in preventing pregnancy, and the need for continued use of condoms to prevent sexually transmitted infections.
Choice B rationale
While it’s important to inform the client about how to obtain contraceptives, providing a variety of free oral contraceptives from the clinic may not be feasible or appropriate depending on the specific circumstances and regulations.
Choice C rationale
Encouraging the client to discuss her contraceptive needs with her parents could be beneficial, but it’s also important to respect her autonomy and confidentiality. In many places, adolescents have the right to access contraceptive services without parental consent.
Choice D rationale
The requirement for parental consent to receive contraceptives varies by location. In many places, adolescents can access contraceptive services without parental consent.

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During a routine clinic visit, a nurse finds that a 5-year-old girl’s systolic blood pressure is above the 90th percentile. What should be the nurse’s subsequent action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving the client?

Correct Answer is D

Explanation

During a sports physical examination, a 15-year-old female expresses her desire for oral contraceptives. She mentions that she is sexually active and prefers not to inform her parents. What should be the nurse’s course of action?

Correct Answer is A

Explanation

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