What should be the emergency department nurse's next action when ...

[lak]

What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hg?
 
  a. Alert the physician about the systolic blood pressure.
  b. Comfort the child and assess the respiratory rate.
  c. Assess the child's responsiveness to the environment.
  d. Alert the physician that the child may need intravenous fluids.

Question 2

A child tells the school nurse that he can't see things at a distance very clearly but he can read up close fine. The nurse knows that the refractive disorder causing the ability to see distant objects less clearly than those close up is termed:
 
  a. hyphema.
  b. astigmatism.
  c. amblyopia.
  d. myopia.

[jointhecircus]

Answer to Question 1

A
Hypotension is a late sign of shock in children. The lower limit for systolic blood pressure for a child older than 1 year is 70 mm Hg plus two times the child's age in years. A systolic blood pressure of 58 mm Hg calls for immediate action. The nurse should be direct in relaying the child's condition to the physician. Comforting the child and assessing the respiratory rate do not address the problem of shock, which requires immediate intervention. Assessing the child's responsiveness is included in a neurological assessment. It does not address the systolic blood pressure of 58 mm Hg. Although this child most likely requires intravenous fluids, the physician must be apprised of the systolic blood pressure so that appropriate intervention can be initiated.

Answer to Question 2

D
Myopic patients have the ability to see near objects more clearly than those at a distance; it is caused by the image focusing beyond the retina. Hyphema includes hemorrhage in the anterior chamber and is not a refractive disorder. Astigmatism is caused by an abnormal curvature of the cornea or lens. Amblyopia is a problem of reduced visual acuity not correctable by refraction.

[lak]

TYSM

[mcabuhat]

Excellent