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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Notifying a religious leader may provide spiritual support but is secondary to facilitating the family’s immediate grieving by viewing the deceased. Cleaning the body allows closure, making this less urgent and incorrect for the initial nursing action to support the family’s grief in the ER.
Choice B reason: Arranging funeral home transfer is logistical and less immediate than helping the family process loss through viewing the deceased. Preparing the body supports emotional closure, making this secondary and incorrect for the initial action to aid the family’s grieving process in the ER.
Choice C reason: Cleaning and presenting the deceased allows the family to view their loved one, facilitating closure and beginning the grieving process. This aligns with trauma nursing principles for supporting bereaved families, making it the best initial action in this tragic car accident scenario.
Choice D reason: Presenting personal belongings is meaningful but less critical than allowing the family to see the deceased, which supports immediate grief processing. Body preparation takes precedence for closure, making this less impactful and incorrect for the initial grieving support action in the ER.
Correct Answer is A
Explanation
Choice A reason: Burn fluid replacement follows the Parkland formula, with half the total volume (24 ounces = 12 ounces) given in the first 8 hours. From 10:00 AM to 6:00 PM (8 hours), the child receives 12 ounces, aligning with pediatric burn care protocols, making this the correct choice.
Choice B reason: By 4:00 PM (6 hours), the child receives less than half the 24 ounces, as half (12 ounces) is given over 8 hours. The 12-ounce mark is reached by 6:00 PM, making this incorrect, as it overestimates fluid delivery in the shorter timeframe for burn treatment.
Choice C reason: 18 ounces by 4:00 PM (6 hours) exceeds the standard rate, as only half (12 ounces) of 24 ounces is given in 8 hours. The correct amount is 12 ounces by 6:00 PM, making this incorrect for burn fluid replacement timing in the pediatric patient’s treatment.
Choice D reason: 18 ounces by 6:00 PM (8 hours) is incorrect, as only half the total (12 ounces) is administered in the first 8 hours per burn protocols. The correct volume is 12 ounces, making this incorrect for the standard fluid replacement schedule in pediatric burn care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.