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 correct answer is choice C. Activity intolerance related to generalized weakness.

Choice A rationale:

Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.

Choice B rationale:

Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.

Choice C rationale:

Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.

Choice D rationale:

Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.

The correct answer is choice C: "Salt restriction."

Choice A rationale:

The requirement of a high protein diet is not typically indicated for a child with nephrosis. Nephrosis, a condition characterized by excessive protein in the urine, indicates a need to reduce protein intake to alleviate kidney stress and proteinuria.

Choice B rationale:

A low fat diet is not a specific requirement for a child with nephrosis. The focus in nephrosis is primarily on protein and salt intake rather than fat content.

Choice C rationale:

Salt restriction is the correct requirement for a child with nephrosis. Nephrosis often leads to fluid retention and edema due to impaired kidney function. Restricting salt intake helps to reduce fluid retention and manage blood pressure.

Choice D rationale:

A high carbohydrate diet is not commonly prescribed for a child with nephrosis. While carbohydrates are a source of energy, they are not a primary consideration in managing nephrosis. The emphasis is more on protein and salt intake.