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A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?
- A. Record the diastolic value as the first Korotkoff sound (K1).
- B. Release the cuff pressure at a rate of about 5 mm Hg/second.
- C. Position the child's arm at the level of the heart.
- D. Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
Correct Answer: C
Rationale: Positioning the arm at heart level ensures accuracy. Diastolic is K5, cuff release should be 2-3 mm Hg/second, and cuff size is ~40% of arm circumference.
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A nurse is reinforcing teaching with the parent of a 15-month-old toddler about nutritional guidelines. Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child will be constipated if they drink more than 6 ounces of juice a day.
- B. My child's intake of calcium should average 500 milligrams every day.
- C. My child should consume 1,500 to 1,800 calories each day by the time they turn 2.
- D. My child's appetite will increase suddenly when they turn 18 months old.
Correct Answer: B
Rationale: A 15-month-old toddler needs about 500 milligrams of calcium per day to support bone growth and development. Excessive juice does not cause constipation but can reduce appetite for other foods. Toddlers need approximately 1,000 to 1,300 calories per day, so 1,500-1,800 calories is excessive. There is no specific age-related sudden appetite increase at 18 months.
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
- A. Use an automated lancet device to puncture the heel.
- B. Apply limb restraints to the infant.
- C. Puncture the heel at the inner aspect of the heel.
- D. Cleanse the area with povidone iodine.
Correct Answer: A
Rationale: An automated lancet device ensures a controlled puncture, minimizing discomfort. Restraints are unnecessary, the inner heel is not the correct site, and povidone iodine is not typically used for heel sticks.
A nurse is reinforcing teaching with the parent of a child who is newly diagnosed with diabetes mellitus. Which of the following guidelines should the nurse include?
- A. Your child should increase carbohydrate intake when sick.
- B. You should omit your child's bedtime snack.
- C. Your child's meal plan should consist mainly of proteins.
- D. Your child's meal plan should include a snack before physical activity.
Correct Answer: D
Rationale: A snack before activity prevents hypoglycemia. Increased carbs when sick requires guidance, bedtime snacks prevent overnight lows, and meals should balance nutrients, not focus on proteins.
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
- A. Insomnia
- B. Irritability
- C. Diarrhea
- D. Hypothermia
Correct Answer: B
Rationale: Irritability may signal increased intracranial pressure post-head injury, requiring prompt reporting. Insomnia, diarrhea, and hypothermia are less directly related.