A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?
A 10-year-old client who had an appendectomy
A 3-year-old toddler who has a broken elbow
A 4-year-old preschooler who had a tonsillectomy
A 4-day-old infant who had a repair of a birth defect
A 4-day-old infant who had a repair of a birth defect
The Correct Answer is D
Choice A reason: The CRIES pain scale is not suitable for a 10-year-old as this scale is designed for neonates, typically those who are 0 to 6 months old.
Choice B reason: A 3-year-old toddler would be better assessed with a pain scale that allows for their level of understanding and communication, such as the Faces Pain Scale-Revised.
Choice C reason: A 4-year-old preschooler can typically communicate their pain verbally or by using a faces pain scale, making the CRIES scale less appropriate.
Choice D reason: The CRIES pain scale is specifically designed for neonates and is appropriate for assessing pain in a 4-day-old infant who cannot verbally communicate their pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A systemic infection would affect the entire body or multiple systems, not just the urinary tract. While a urinary tract infection can become systemic if it leads to sepsis, the scenario provided does not specify such progression.
Choice B reason: A health care-associated infection (HAI) is an infection that a patient acquires while receiving treatment for another condition within a healthcare setting. Since the infection occurred after the insertion of a urinary catheter in a hospital, it is considered an HAI.
Choice C reason: An endogenous infection originates from the host's own microbial flora. The scenario does not provide enough information to determine if the infection was caused by the client's own flora or by external sources.
Choice D reason: An exogenous infection comes from outside the body. While the urinary tract infection could be exogenous, the scenario suggests it is more likely to be health care-associated due to the timing and context of the catheter insertion.
Correct Answer is D
Explanation
Choice A reason: The first and immediate action after a needlestick injury is to wash the puncture site with soap and water. This helps to remove any pathogens that may have been introduced into the puncture site.
Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.
Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.
Choice D reason: Postexposure prophylaxis (PEP) should be started as soon as possible, ideally within hours and no later than 72 hours after potential exposure to HIV. Waiting until the following day could decrease the effectiveness of PEP.
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