A 5-year-old child is scheduled for a vaccination. The nurse wants the child to self-report pain. The child can understand pictures but has difficulty with numbers. Which pain assessment tool is MOST appropriate?
Numeric Rating Scale (0-10)
FLACC scale
Visual Analog Scale
Oucher Pain Scale
The Correct Answer is D
A. This scale requires the child to understand numbers and quantify pain. A 5-year-old who has difficulty with numbers cannot reliably use this scale, making it inappropriate.
B. While FLACC is excellent for observational assessment of nonverbal or pre-verbal children, it does not allow the child to self-report pain. Since the nurse wants the child to self-report, this is not the best choice.
C. This scale requires the child to mark a point on a line representing their pain intensity. It also requires abstract thinking and fine motor skills, which may be challenging for a 5-year-old, especially if they can’t reliably understand numbers or gradients.
D. The Oucher scale uses pictures of faces showing increasing pain intensity along with a numeric scale. For children who understand pictures but struggle with numbers, this scale allows them to self-report pain by pointing to the face that matches their discomfort. It is validated for children aged 3–12 years, making it the most appropriate choice for a 5-year-old who can use pictorial cues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Infants, especially those under 6 months, may present with apnea and cyanosis during coughing paroxysms instead of the classic “whoop,” as their respiratory muscles are immature. This is a common severe manifestation in young infants.
B. Inspiratory stridor and a barking cough are characteristic of croup, not pertussis. Croup is usually viral in origin and presents with hoarseness and upper airway obstruction, which differs from pertussis.
C. Wheezing with exertional dyspnea is more typical of asthma or bronchiolitis, not pertussis. While pertussis can cause hypoxia, wheezing is not a defining feature.
D. The paroxysmal stage of pertussis is characterized by repetitive coughing spells followed by a high-pitched inspiratory “whoop”. This is classic for older infants and children, though it may be absent in young infants.
E. In the catarrhal stage, pertussis often begins as a mild, dry cough resembling a common cold, which gradually progresses to severe paroxysms. Nighttime exacerbation is common.
Correct Answer is B
Explanation
A. Genetic testing for CFTR mutations is incorrect as the primary diagnostic tool. While genetic testing can identify specific CF mutations and is useful for screening or confirming atypical cases, it is not considered the first-line gold standard for diagnosis.
B. Sweat chloride test is correct. The sweat chloride test measures the concentration of chloride in sweat, which is abnormally elevated in individuals with cystic fibrosis due to defective CFTR channels. A chloride concentration ≥60 mmol/L on two separate occasions confirms the diagnosis. It remains the gold standard diagnostic test for CF in children.
C. Chest x-ray is incorrect because it is not diagnostic for CF. Although chest x-rays may show structural lung changes such as hyperinflation or bronchiectasis in advanced disease, they cannot confirm CF on their own.
D. Pulmonary function tests (PFTs) are incorrect for initial diagnosis in young children. PFTs assess lung function and disease progression but are not reliable for confirming CF, especially in a 3-year-old who may not be able to perform the maneuvers required.
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