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.
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Correct Answer is B
Explanation
Choice A reason: Consents for surgery involve legal and procedural details, typically handled by providers, not nurses. Educating on growth and development is within nursing scope, making this incorrect, as it exceeds the nurse’s role in instructing families of a child with a chronic illness.
Choice B reason: Instructing on growth and development changes helps parents understand their child’s progress despite chronic illness, within the nurse’s educational role. This aligns with pediatric nursing practice, making it the correct situation for the nurse to provide instruction in the pediatrician’s office.
Choice C reason: Explaining diagnostic tests and lab work is typically the provider’s responsibility, as it involves medical interpretation. Growth and development education is nurse-appropriate, making this incorrect, as it falls outside the nurse’s primary instructional role for the chronically ill child’s family.
Choice D reason: Diagnosing secondary problems is a medical responsibility, not within nursing scope for instruction. Growth and development guidance is nurse-led, making this incorrect, as it involves diagnostic communication beyond the nurse’s role in educating the family of the chronically ill child.
Correct Answer is D
Explanation
Choice A reason: Rheumatic fever follows streptococcal infection but typically presents with joint pain, carditis, or rash, not puffy eyes or abnormal urine. Glomerulonephritis better matches the symptoms post-infection, making this incorrect for the suspected condition based on the child’s presentation and history.
Choice B reason: Lipoid nephrosis causes edema and proteinuria but is not typically linked to recent infections or hematuria. Acute glomerulonephritis, often post-streptococcal, explains puffy eyes and abnormal urine, making this less fitting and incorrect for the child’s symptoms following ear infections.
Choice C reason: Urinary tract infections cause dysuria or frequency, not puffy eyes or hematuria post-infection. Acute glomerulonephritis aligns with the history of ear infections (possible streptococcal link) and symptoms, making this incorrect for the suspected condition in this child with these signs.
Choice D reason: Acute glomerulonephritis, often post-streptococcal (e.g., after ear infections), causes hematuria (“funny” urine), periorbital edema (puffy eyes), and headache. This aligns with pediatric nephrology evidence, making it the correct condition the nurse suspects based on the child’s symptoms and medical history.
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