A student nurse records a systolic blood pressure of 106 mm Hg ...

[meagbuch]

A student nurse records a systolic blood pressure of 106 mm Hg for a 4-year-old child. Which response by the registered nurse is best?
 
  A.
  Ask the student if this is a normal finding.
  B.
  Have the student repeat the blood pressure.
  C.
  Refer the family to a health-care provider.
  D.
  Tell the student to document the results.

Question 2

A nurse is concerned that a child with pulmonary hypertension (PA) is developing heart failure. Which manifestation would the nurse assess for first?
 
  A.
  Cough
  B.
  Dyspnea
  C.
  Extremity edema
  D.
  Tachycardia

[recede]

Answer to Question 1

ANS: C
This blood pressure is in the 95th percentile for age. For screening purposes, a blood pressure greater than 20 mm Hg above normal for the child's age is considered a red flag for hypertension, and the child should be referred to a health-care provider. The other options are all appropriate but are not as important as referring the child for further workup.

Answer to Question 2

ANS: C
As the pressure in the lungs increases in the child with PA, the right ventricle hypertrophies and will eventually fail. Manifestations of right-sided failure include peripheral edema. Lung manifestations are seen in left-sided heart failure. Tachycardia is nonspecific. Although both sides of the heart can eventually fail, the first signs and symptoms will be of right-sided failure.

[meagbuch]

TYSM

[cici]

Excellent