A 5-year-old preschooler is recovering from a tonsillectomy and is able to speak but has difficulty understanding numbers. Which pain assessment tool should the nurse use?
Numeric Rating Scale
Visual Analog Scale
FLACC
Faces Pain Scale-Revised (Wong-Baker)
The Correct Answer is D
A. This scale asks the child to verbally rate their pain on a scale from 0 (no pain) to 10 (worst pain). It requires understanding of numbers, abstract thinking, and the ability to quantify pain, which is beyond the cognitive level of most 5-year-old preschoolers. Since the child in this scenario has difficulty understanding numbers, using the NRS would likely lead to inaccurate or unreliable pain assessment.
B. The VAS requires the child to mark a point along a continuous line representing pain intensity, usually anchored with “no pain” at one end and “worst pain” at the other. This tool requires abstract thinking, spatial awareness, and fine motor skills, which preschoolers may not have fully developed. A 5-year-old may not comprehend the concept of a continuous gradient or how to place a mark accurately, making this scale inappropriate.
C. The FLACC scale assesses pain based on observational behaviors: Face, Legs, Activity, Cry, and Consolability. It is designed for infants, toddlers, or children who are nonverbal or unable to self-report. While effective for behavioral assessment, FLACC does not allow the child to self-report pain, which is considered the gold standard whenever possible. Since this child can speak, the nurse should use a tool that allows self-expression rather than relying solely on observation.
D. This scale presents a series of faces ranging from a happy face (no pain) to a crying face (worst pain). Children point to the face that best represents their pain, allowing self-reporting without needing to understand numbers. It is validated for children aged 4–12 years and is developmentally appropriate for a 5-year-old preschooler. It accommodates children who have difficulty with numerical concepts but can interpret visual expressions of discomfort. Additionally, it encourages active participation in pain assessment, improves communication between the child and caregiver, and can guide pain management decisions accurately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Macrosomia, defined as a birth weight greater than 4,000–4,500 grams, is the most common fetal complication associated with gestational diabetes. Hyperglycemia in the mother leads to increased glucose transfer across the placenta, stimulating fetal pancreatic insulin production. Fetal hyperinsulinemia acts as a growth-promoting hormone, resulting in excessive fat and muscle deposition and ultimately large-for-gestational-age infants. Macrosomia increases the risk of birth injuries such as shoulder dystocia, clavicle fractures, and the need for cesarean delivery.
B. Preterm birth is not the primary risk associated with GDM. While poorly controlled diabetes can contribute to preterm labor, it is less common than macrosomia. The main concern in GDM is excessive fetal growth, not premature delivery.
C. Low birth weight is not typically associated with gestational diabetes. In fact, infants of mothers with poorly controlled GDM are often larger than average, not smaller, due to fetal hyperinsulinemia and increased nutrient availability.
D. Congenital anomalies, particularly neural tube defects or central nervous system defects, are primarily associated with pregestational diabetes rather than GDM. Gestational diabetes develops later in pregnancy (usually after 24 weeks) when organogenesis has largely occurred, so the risk for major congenital anomalies is minimal.
Correct Answer is B
Explanation
A. This option is incorrect because it describes Rh incompatibility, not ABO incompatibility. ABO incompatibility does not depend on Rh status and cannot be prevented with Rh immunoglobulin (Rho(D) immune globulin). Additionally, ABO incompatibility commonly causes jaundice, not just mild anemia.
B. This statement is correct. ABO incompatibility occurs when maternal IgG antibodies (anti-A or anti-B), most commonly in a type O mother, cross the placenta and attack fetal red blood cells that carry A or B antigens. This can result in hemolysis, leading to neonatal jaundice and mild anemia. ABO incompatibility is more common than Rh incompatibility, although it is usually less severe.
C. This option is incorrect because ABO incompatibility does not require prior blood transfusions or sensitization. Mothers with type O blood naturally have anti-A and anti-B antibodies, which can affect the fetus even during a first pregnancy.
D. This statement is incorrect because ABO incompatibility occurs when the mother and infant have different blood types, not the same blood type. Severe hemolysis and kernicterus requiring exchange transfusion are more characteristic of severe Rh incompatibility, not typical ABO incompatibility, which is usually mild and managed with phototherapy.
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.