A nurse is about to administer a vaccination to a 4 year old. What developmental response to this painful procedure is MOST likely for a preschool aged child.
The child withdraws and attempts to hide because they think the pain is a form of punishment.
The child denies being scared about pain in an attempt to seem brave, and withdraws to a game on mom's phone.
The child makes facial expressions such as brow contracting and chin quivering in anticipation of the pain.
The child kicks, hits and cries due to lack of control over the situation.
The Correct Answer is C
Rationale:
A. The child withdraws and attempts to hide because they think the pain is a form of punishment: This is more typical of toddlers who have limited understanding and may associate pain with punishment, rather than preschoolers who have a better grasp of cause and effect.
B. The child denies being scared about pain in an attempt to seem brave, and withdraws to a game on mom's phone: While distraction techniques are effective, preschoolers are more likely to show visible signs of distress rather than denying fear completely, as their emotional expression is more open.
C. The child makes facial expressions such as brow contracting and chin quivering in anticipation of the pain: Preschool-aged children often express fear and anxiety about painful procedures through facial cues and body language, showing clear anticipation and emotional response.
D. The child kicks, hits and cries due to lack of control over the situation: This aggressive and oppositional behavior is more characteristic of toddlers or children with less developed coping skills, rather than preschoolers who generally have more emotional regulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Continuous swallowing while asleep: Continuous swallowing can indicate that the child is swallowing blood from a bleeding site in the throat. This subtle but important sign often appears early after tonsillectomy and signals the need for immediate assessment.
B. Decreased blood pressure: A drop in blood pressure is a late indicator of significant hemorrhage and hypovolemia. Waiting for hypotension before acting risks severe complications, so earlier signs should guide nursing interventions.
C. Throat pain: Throat pain is a normal postoperative symptom due to tissue trauma from surgery. While uncomfortable, it does not necessarily indicate bleeding and should be differentiated from signs of hemorrhage.
D. Dark brown, bloody emesis: Vomiting dark brown blood reflects older, clotted blood and usually occurs after bleeding has already been ongoing. It is a later sign compared to subtle early indicators like continuous swallowing.
Correct Answer is B
Explanation
Rationale:
A. Bradycardia: Bradycardia is a late sign of increased ICP and typically appears after other symptoms like changes in behavior or consciousness have developed. Early detection focuses more on neurological changes rather than vital sign alterations.
B. Restlessness and confusion: These are early neurological signs indicating altered cerebral function due to increased ICP. Changes in behavior, such as irritability, restlessness, and confusion, often precede vital sign changes and are key for prompt intervention.
C. Large amounts of very dilute urine: This finding suggests possible diabetes insipidus or fluid imbalance, which can occur with severe brain injury but is not an early indicator of increased ICP specifically. It is not a primary sign for monitoring ICP.
D. Widened pulse pressure: Widened pulse pressure is part of Cushing’s triad, a late and serious sign of increased ICP that occurs after the brainstem is compromised. Early signs are more subtle and neurological rather than cardiovascular.
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.