Author Question: A student nurse records a systolic blood pressure of 106 mm Hg for a 4-year-old child. Which ... (Read 74 times)

meagbuch · **on:** Jun 28, 2018

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 · **Reply #1 on:** Jun 28, 2018

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.