A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he is having no pain. Which nursing intervention should the nurse prioritize when assessing this child?

Observe him for physical signs which might indicate pain.

Ask him to show you his pain level using the color pain scale.

Explain to his caregiver that his pain level shows he is getting better quickly.

Tell him to let you know if he begins to feel pain.

Answer and Explanation

The Correct Answer is A

Choice A reason: Observing for physical signs like grimacing or guarding ensures accurate pain assessment, as a 10-year-old may underreport pain. This aligns with pediatric pain assessment protocols, making it the prioritized intervention to verify the child’s claim of no pain post-appendectomy accurately.

Choice B reason: A color pain scale relies on the child’s verbal report, which may be unreliable if he’s minimizing pain. Observing physical signs is more objective, making this secondary and incorrect compared to the nurse’s priority of assessing for hidden pain in the post-surgical child.

Choice C reason: Explaining to the caregiver assumes no pain without objective assessment, risking missed discomfort. Observing physical signs confirms the child’s status, making this premature and incorrect compared to the nurse’s role in thoroughly assessing pain in the 10-year-old post-appendectomy.

Choice D reason: Asking the child to report pain later depends on his willingness, which may be inconsistent. Observing physical signs provides immediate data, making this passive and incorrect compared to the nurse’s priority of actively assessing for pain in the child post-appendectomy procedure.

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Correct Answer is C

Explanation

Choice A reason: Using tweezers risks ear canal injury or pushing paper deeper in a 2-year-old, potentially causing trauma. Professional evaluation ensures safe removal, making this dangerous and incorrect compared to advising immediate medical attention to address the potential foreign object in the child’s ear safely.

Choice B reason: Delaying care for irritation risks complications like infection or eardrum damage from a foreign object in a 2-year-old. Immediate provider assessment is safer, making this inadequate and incorrect compared to prioritizing prompt medical evaluation for the child’s potential ear issue.

Choice C reason: Immediate care provider evaluation ensures safe removal of any paper, preventing ear damage or infection in a 2-year-old. Advising against inserting objects protects the child, aligning with pediatric safety protocols, making this the correct response to address the caregiver’s concern effectively.

Choice D reason: Washing the ear with a syringe may push paper deeper or injure a 2-year-old’s delicate ear canal. Professional intervention is needed, making this risky and incorrect compared to seeking immediate medical evaluation to safely address the potential foreign object in the child’s ear.

A. “This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, stupor, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome.” B. “This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome.” C. “This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution.” D. “This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus.”

Correct Answer is A

Explanation

Choice A reason: Half an aspirin with a viral infection poses a small Reye syndrome risk, warranting monitoring for symptoms like lethargy or vomiting. This aligns with pediatric safety guidelines, making it the best response to inform the mother while ensuring vigilance for the 9-year-old’s health.

Choice B reason: Nasal discharge and sneezing are unrelated to Reye syndrome, which involves neurological symptoms like stupor. Monitoring for lethargy or vomiting is correct, making this incorrect, as it lists irrelevant symptoms for the mother’s concern about Reye syndrome in her child.

Choice C reason: Admitting for observation overstates the risk, as a single half aspirin rarely causes Reye syndrome. Monitoring for specific symptoms is sufficient, making this alarmist and incorrect compared to the nurse’s balanced response to the mother’s concern about the viral infection.

Choice D reason: Downplaying the risk as unlikely ignores the potential, though rare, link between aspirin and Reye syndrome in viral infections. Monitoring for symptoms is prudent, making this dismissive and incorrect compared to advising vigilance for the 9-year-old’s safety post-aspirin use.

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A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he is having no pain. Which nursing intervention should the nurse prioritize when assessing this child?

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Naxlex Comprehensive Predictor Exams

The caregiver of a 2-year-old calls the clinic concerned that her child may have pushed paper into her ears, and she asks the nurse what to do. The mother found the child pushing on her ears with torn paper on the floor in front of her. What would be the appropriate response by the nurse?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he is having no pain. Which nursing intervention should the nurse prioritize when assessing this child?