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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Lesions may extend to hairline or neck.
Choice A rationale:
Central clearing is not a prominent indicator of Tinea capitis. Tinea capitis is a fungal infection of the scalp and hair shafts, commonly caused by dermatophytes like Trichophyton species. The characteristic features include scaling, erythema, pustules, and hair loss. Unlike some other fungal infections, Tinea capitis does not typically have central clearing.
Choice B rationale:
Lesions extending to the hairline or neck is a correct aspect to include in education about Tinea capitis. The infection usually starts as small, scaly patches on the scalp and can progress to larger areas. It can extend to the hairline, neck, and even eyebrows and eyelashes. This is important information to convey to ensure proper recognition and timely treatment.
Choice C rationale:
Transmission of Tinea capitis mostly occurs from human-to-human rather than from dogs. While some animals can carry fungal infections that affect the skin, Tinea capitis is primarily spread through direct contact with an infected person or contaminated objects like combs, hats, and pillows.
Choice D rationale:
The appearance of Tinea capitis is not usually unilateral. This condition often presents with multiple, scattered areas of involvement on the scalp. It can cause varying degrees of inflammation, scaling, and hair loss in different areas, which may not follow a unilateral pattern.
Correct Answer is D
Explanation
The correct answer is choice E. Board games.
Choice A rationale:
Computer games might not be the best choice for a child with osteomyelitis. These games involve prolonged screen time and limited physical movement, which could potentially hinder the child's recovery.
Choice B rationale:
Paper and paints involve a level of physical activity that might not be suitable for a child with osteomyelitis. The child's movement might be restricted due to the condition, and activities that require fine motor skills might not be comfortable for them.
Choice C rationale:
Jack-in-the-box involves sudden surprises and might startle the child, which could be detrimental to their recovery. Children with osteomyelitis might be dealing with pain and discomfort, so it's important to avoid activities that could cause unnecessary distress.
Choice D rationale:
Stuffed animals might be a comforting option for the child. However, the child might also experience pain or discomfort when handling stuffed animals due to their condition. It's better to choose activities that don't involve physical contact that could potentially exacerbate the child's symptoms.
Choice E rationale:
Board games are a suitable choice for a child with osteomyelitis. They provide mental stimulation and entertainment without requiring excessive physical activity. Board games also promote social interaction if played with others, which is important for the child's emotional well-being during their hospital stay.
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