The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff?
The cuff bladder covers 50% to 66% of the length of the upper arm.
The cuff is labeled "toddler.".
The cuff bladder width is approximately 40% of the circumference of the upper arm.
The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
The Correct Answer is A
The correct answer is choice A. The cuff bladder covers 50% to 66% of the length of the upper arm.
Choice A rationale:
Selecting a blood pressure cuff with a bladder that covers 50% to 66% of the length of the upper arm is the appropriate criterion for determining the cuff size for a 2-year-old boy. This range ensures accurate blood pressure measurement by ensuring a proper fit on the arm. If the cuff bladder is too small or too large, it can result in inaccurate readings.
Choice B rationale:
The label "toddler" on the cuff might be helpful in identifying the intended age group, but it doesn't provide precise measurements for cuff sizing. Relying solely on a label might not account for variations in arm sizes within the toddler age group.
Choice C rationale:
The cuff bladder width being 40% of the circumference of the upper arm might not be as accurate as the length-based criterion. A cuff that fits the arm's length is more critical in ensuring proper inflation and accurate blood pressure measurement.
Choice D rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm might result in an excessively large cuff for a 2-year-old, which can lead to inaccurate readings. Length-based sizing is more appropriate for accuracy in this scenario.
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Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
Drawing is the most appropriate activity for developing fine motor skills in school-age children. Drawing involves precise hand movements, control of a writing instrument, and attention to detail. These skills contribute to fine motor skill development and hand-eye coordination.
Choice B rationale:
Singing is not directly related to fine motor skill development. While it can promote cognitive and social development, it does not require the same level of fine motor control as activities like drawing or writing.
Choice C rationale:
Swimming is a gross motor activity that focuses more on large muscle groups and overall coordination. It does not specifically target the refinement of fine motor skills.
Choice D rationale:
Soccer is also a gross motor activity that involves running, kicking, and coordination with teammates. While it promotes physical fitness and coordination, it does not emphasize the fine motor control required for activities like drawing.
Correct Answer is C
Explanation
The correct answer is choice C. Therapeutic management includes administration of gamma globulin and aspirin.
Choice A rationale:
The child's fever in Kawasaki disease is not usually responsive to antibiotics within 48 hours. Kawasaki disease is an inflammatory condition of blood vessels, and it doesn't typically respond to antibiotics. The fever associated with Kawasaki disease often persists even with appropriate treatment, and the management focuses on reducing inflammation and preventing complications.
Choice B rationale:
Aspirin is not contraindicated in Kawasaki disease. In fact, aspirin is a key component of the therapeutic management of Kawasaki disease. It is used to reduce inflammation and prevent the development of coronary artery aneurysms, a severe complication of the disease. However, the dosing of aspirin in Kawasaki disease is different from its use for pain relief, and it should be administered under medical supervision.
Choice C rationale:
Therapeutic management of Kawasaki disease does include administration of gamma globulin and aspirin. Gamma globulin is given to reduce the risk of coronary artery involvement and aneurysm formation. Aspirin, at a specific dose regimen, is used to decrease inflammation and platelet aggregation, thus preventing clot formation in the coronary arteries.
Choice D rationale:
The principal area of involvement in Kawasaki disease is not the joints. Kawasaki disease primarily affects the blood vessels, particularly the coronary arteries. The inflammation of these arteries can lead to the development of coronary artery aneurysms, which is a critical concern in Kawasaki disease. Joint involvement is not a prominent feature of this condition.
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