During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?

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

Measure the child's blood pressure three times during the visit and determine the highest of the readings.

Conduct a head-to-toe assessment and omit repeated blood pressures during the examination.

Take the blood pressure two more times during the visit and determine the average of the three readings.

Answer and Explanation

The Correct Answer is D

If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks

A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings

B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination

C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.

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Correct Answer is A

Explanation

The nurse should report a positive rapid strep test of the oropharynx to the healthcare provider. Acute glomerulonephritis is often caused by a recent streptococcal infection, and a positive rapid strep test would confirm this as the underlying cause

A blood pressure of 88/50 mmHg is within the normal range for a child and would not need to be reported.

A maculopapular rash over the trunk of the body is not typically associated with acute glomerulonephritis and would not need to be reported.

Weight loss may occur with acute glomerulonephritis due to decreased appetite, but it is not an urgent finding that needs to be reported immediately.

A. Ibuprofen should be used prophylactically to prevent febrile seizures. B. Provide the child with a sponge bath for temperatures over 100.6°F (38.1° C. Reassure the parents that febrile seizures decrease as the child grows older. D. Avoid excessive visual stimuli because it can precipitate seizure activity.

Correct Answer is C

Explanation

The nurse should reassure the parents that febrile seizures typically decrease in frequency as the child grows older. Most children outgrow febrile seizures by the age of 5 years.

Ibuprofen is not typically used prophylactically to prevent febrile seizures.

Providing the child with a sponge bath for temperatures over 100.6°F (38.1° C) can help to lower the fever, but it will not necessarily prevent febrile seizures.

Avoiding excessive visual stimuli is not necessary for children with febrile seizures, as this type of seizure is triggered by a fever rather than visual stimuli.

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During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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