During a routine health assessment, the nurse notes that an ...

[tfester]

During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?
 
  a. Recheck head control at next visit.
  b. Teach the parents appropriate exercises.
  c. Schedule the child for further evaluation.
  d. Refer the child for further evaluation if the anterior fontanel is still open.

Question 2

The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?
 
  a. Use the small cuff.
  b. Use the large cuff.
  c. Use either cuff using the palpation method.
  d. Wait to take the blood pressure until a proper cuff can be located.

[sultansheikh]

Answer to Question 1

ANS: C
Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.

Answer to Question 2

ANS: B
If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure. Using the small cuff will give an incorrectly high reading. The palpation method will not improve the inaccuracy inherent in the cuff.

[tfester]

TYSM

[emsimon14]

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