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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal fluid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches.
Choice A rationale
While growth in height could be a positive sign of overall health and development, it does not specifically indicate that a VP shunt is functioning properly.
Choice C rationale
The presence of an intracranial pressure (ICP) monitoring probe does not indicate whether the shunt is functioning properly. The probe is a device used to measure ICP and does not provide information about the functionality of the shunt.
Choice D rationale
Being afebrile with normal vital signs postoperatively is a positive sign, but it does not specifically indicate that the shunt is functioning properly.
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are not typically associated with acute respiratory distress in a child with respiratory syncytial virus (RSV). Diaphragmatic respirations are normal in infants and young children.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and would not typically indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and would not typically indicate acute respiratory distress in a child with RSV45.
Choice D rationale
Flaring of the nares, or nostrils, can be a sign of respiratory distress in infants and young children. It indicates that the child is using additional muscles to breathe, which can occur when the lower airways are blocked or narrowed, as in a severe RSV infection.
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