Nokea
During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?
- A. Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks.
- B. Measure the child's blood pressure three times during the visit and determine the highest of the readings.
- C. Conduct a head-to-toe assessment and omit repeated blood pressures during the examination.
- D. Take the blood pressure two more times during the visit and determine the average of the three readings.
Correct Answer: D
Rationale: Taking the blood pressure two more times and averaging the readings provides a more accurate assessment.
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A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Ask the boy to describe a typical day at school.
- B. Compare the child's vital signs over the past three weeks.
- C. Conduct a complete neurological assessment.
- D. Counsel the parents to pay more attention to the child.
Correct Answer: A
Rationale: Describing a typical school day helps identify potential stressors causing the symptoms, guiding further intervention.
The nurse is caring for a child with hypoparathyroidism who demonstrates a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review?
- A. Potassium.
- B. Chloride.
- C. Sodium.
- D. Calcium.
Correct Answer: D
Rationale: Hypoparathyroidism causes low calcium levels, leading to carpal spasms, so reviewing calcium levels is critical.
A child receives a prescription for loratadine 5 mg by mouth once day. The bottle is labelled 'Loratadine for Oral Suspension, USP 5 mg per 5 mL.' How many teaspoons should the nurse instruct the parent to administer with each dose?
- A. 1 teaspoon
Correct Answer: A
Rationale: 5 mg of loratadine corresponds to 5 mL (1 teaspoon) of the suspension, as per the concentration provided.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to eat a source of sugar if which symptom occurs?
- A. Racing pulse.
- B. Profuse perspiration.
- C. Excessive thirst.
- D. Seeing spots.
Correct Answer: B
Rationale: Profuse perspiration is a symptom of hypoglycemia, requiring immediate sugar intake to raise blood glucose levels.
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and then feeding the infant.
- B. Give the mother positive feedback about the way she administered the medication.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Tell the mother to follow the iron drops with infant formula instead of orange juice.
Correct Answer: B
Rationale: Giving orange juice after iron drops enhances iron absorption due to vitamin C, so positive feedback is appropriate.