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 A
Explanation
The correct answer is choice A. Meconium ileus.
Choice A rationale:
Meconium ileus. This is the earliest recognizable clinical manifestation of cystic fibrosis (CF). Meconium ileus refers to the blockage of the small intestine by thick, sticky meconium, the earliest stool of a newborn. It occurs in the first 24-48 hours of life and can be a sign of underlying cystic fibrosis.
Choice B rationale:
Foul-smelling, frothy, greasy stools. Foul-smelling, frothy, greasy stools are characteristic of malabsorption, which can occur in cystic fibrosis. However, this manifestation typically appears after meconium ileus and is not the earliest recognizable clinical sign.
Choice C rationale:
History of poor intestinal absorption. While poor intestinal absorption is a common consequence of cystic fibrosis, it is not one of the earliest recognizable clinical manifestations. Meconium ileus takes precedence as the primary early sign.
Choice D rationale:
Recurrent pneumonia and lung infections. Recurrent pneumonia and lung infections are common in later stages of cystic fibrosis due to the buildup of thick mucus in the respiratory tract. However, they are not among the earliest recognizable clinical manifestations of the disease. Meconium ileus is the earliest indicator in this context.
Correct Answer is C
Explanation
The correct answer is choice C. Sparse hair.
Choice A rationale:
Sleepiness is not a typical symptom of hypothyroidism. Hypothyroidism, a condition where the thyroid gland doesn't produce enough thyroid hormone, leads to a slower metabolism which can cause fatigue, but not necessarily sleepiness.
Choice B rationale:
Weight loss is not associated with hypothyroidism. In fact, weight gain is a common symptom due to the reduced metabolic rate caused by insufficient thyroid hormone levels.
Choice C rationale:
Sparse hair is a characteristic symptom of hypothyroidism. The thyroid hormones play a crucial role in the growth and maintenance of hair follicles. In hypothyroidism, hair can become brittle, thin, and sparse.
Choice D rationale:
Diarrhea is not a typical symptom of hypothyroidism. Constipation, on the other hand, is more commonly associated with this condition due to the slowed digestive processes caused by low thyroid hormone levels.
Choice E rationale:
Puffiness around the eyes is not typically associated with hypothyroidism. However, it is a symptom of another thyroid disorder known as Graves' disease, which is characterized by hyperthyroidism (overactive thyroid).
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