A 6-year-old child in the pediatric ward has had a minor laceration sutured on the forearm. Vital signs are within normal limits but the child is quiet. withdrawn, and refuses to play. The nurse suspects pain. What action should the nurse take FIRST?
Use a developmentally appropriate pain assessment tool.
Assume the child is fine because vital signs are stable.
offer the child juice and a snack.
Wait until pain is mentioned verbally by the child.
The Correct Answer is A
A. The first action when a child shows behavioral signs of pain, such as being quiet, withdrawn, or refusing to play, is to assess pain accurately using a tool suited to the child’s age and developmental level. For a 6-year-old, tools like the Faces Pain Scale–Revised (FPS-R) or Oucher Pain Scale are appropriate. Accurate assessment is essential to guide appropriate pain management interventions and ensure the child’s comfort.
B. Vital signs may not always reflect pain, especially in children. Behavioral and psychological cues are often more sensitive indicators of pain than vital signs in pediatric patients. Assuming the child is fine could lead to undertreatment of pain.
C. While offering food or drink may provide comfort, it does not address the underlying pain. Without assessment, the nurse cannot determine if the child’s withdrawal is due to pain or another cause. This is not the first or priority action.
D. Relying on self-report alone may delay pain recognition and treatment, particularly if the child is quiet, withdrawn, or fearful. Children often do not verbalize pain immediately, so proactive assessment is crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hydralazine is an antihypertensive used to manage severe hypertension in preeclampsia. While controlling blood pressure is essential in preeclampsia, hydralazine does not reverse the toxic effects of magnesium. Administering hydralazine in this context would not address the immediate life-threatening neuromuscular or respiratory depression.
B. Methylergonovine is a uterotonic agent used to treat postpartum hemorrhage by stimulating uterine contractions. It has no effect on magnesium toxicity and is unrelated to seizure prophylaxis or respiratory function. Administering this drug would not correct the client’s critical condition.
C. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Magnesium sulfate toxicity is not opioid-related, so Narcan would not improve respiratory rate, restore reflexes, or address neuromuscular blockade caused by magnesium.
D. Calcium gluconate is the specific antidote for magnesium sulfate toxicity. It works by antagonizing the effects of magnesium at the neuromuscular junction, restoring deep tendon reflexes, and improving respiratory muscle function. Administration is intravenous, slow, and under close monitoring. Simultaneously, the magnesium infusion should be stopped immediately to prevent further accumulation. After stabilization, the nurse should monitor vital signs, urine output, reflexes, and serum magnesium levels to ensure safe recovery.
Correct Answer is A
Explanation
A. These are classic signs of epiglottitis, a potentially life-threatening condition caused by inflammation and swelling of the epiglottis, usually from Haemophilus influenzae type b. The child often presents suddenly, is toxic-appearing, prefers to sit upright leaning forward (tripod position) to ease breathing, has drooling due to inability to swallow, and may have muffled or hoarse voice. Stridor may develop as airway obstruction worsens. This is a medical emergency.
B. These are symptoms of upper respiratory tract infections, such as the common cold, and are not indicative of epiglottitis, which presents more acutely and severely.
C. Wheezing and cough are more typical of lower airway diseases like croup or bronchiolitis, not epiglottitis. Difficulty swallowing alone is not sufficient without drooling and tripod positioning.
D. These are classic for viral croup, which affects the larynx and trachea. Epiglottitis differs because it progresses rapidly, causes drooling, and children often refuse to lie down.
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