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 D
Explanation
A. Developmental milestones follow predictable sequences, but the exact age at which each child reaches them can vary. Expecting all babies to reach milestones at the same age is unrealistic and does not reflect normal variation in growth and development.
B. While gross motor skills like walking often develop alongside fine motor skills, fine motor development does not occur automatically. It requires practice, coordination, and maturation of muscles and nervous system pathways.
C. Genetics play a significant role in growth, influencing height, weight, body proportions, and sometimes developmental timing. Denying the influence of genetics misrepresents a key factor in growth and development.
D. This statement reflects an accurate understanding of developmental principles. Growth and developmental milestones occur in a predictable sequence (cephalocaudal, proximodistal, and simple-to-complex patterns), but the timing can vary for each child. This acknowledges normal individual differences while recognizing typical developmental patterns.
Correct Answer is C
Explanation
A. While cold compresses can reduce local pain and inflammation, they do not address the systemic risk of tetanus. Given the child’s symptoms (stiff jaw, muscle spasms, difficulty swallowing) 10 days after stepping on a rusty nail, tetanus is suspected, and simply treating the wound locally is insufficient.
B. Muscle stiffness and spasms in tetanus are caused by neurotoxin effects on the nervous system, not inactivity. Ambulation does not prevent the progression of tetanus and could increase the risk of falls or injury.
C. The child’s clinical presentation is consistent with tetanus, which is a medical emergency. The priority intervention is to neutralize the toxin and provide active and passive immunization. The tetanus booster stimulates active immunity, while tetanus immune globulin (TIG) provides immediate passive immunity to neutralize circulating toxin. This intervention is life-saving and takes priority over local wound care or antibiotics.
D. Antibiotics like metronidazole or penicillin are used to reduce bacterial load, but they do not neutralize circulating tetanus toxin and are secondary to immediate immunotherapy. Delaying TIG while focusing only on antibiotics could be fatal.
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.