A nurse is assessing a 4-year-old child following a surgical procedure. Which of the following pain rating scales should the nurse use?
Oucher pain rating scale
Word-Graphic rating scale
Numeric rating scale
Visual analog scale
The Correct Answer is A
A. Oucher pain rating scale: The Oucher pain rating scale uses pictures of children's faces to represent varying degrees of pain intensity. This scale is specifically designed for young children and can be effective in assessing pain in preschool-aged children who may not yet be able to accurately use verbal descriptors to express their pain.
B. Word-Graphic rating scale: This type of scale presents both words and pictures to represent different levels of pain intensity. While it may be suitable for older children who can understand and use words to describe their pain, it may be less effective for a 4-year-old child who is still developing language skills.
C. Numeric rating scale: Numeric rating scales typically ask the child to rate their pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. While this scale may be appropriate for older children, it may be challenging for a 4-year-old to understand and use numbers to describe their pain.
D. Visual analog scale: Visual analog scales typically consist of a line with endpoints labeled "no pain" and "worst pain imaginable," with the child asked to mark or point to the spot on the line that represents their pain level. While this scale may be suitable for older children and adults, it may be too abstract for a 4-year-old child to understand and use effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Steatorrhea: Steatorrhea refers to the presence of fat in the stool, which can indicate malabsorption or digestive issues, but it is not a typical symptom of a urinary tract infection (UTI). Therefore, it is not relevant to consider steatorrhea in the context of a UTI.
B. Jaundice: Jaundice is characterized by yellowing of the skin and eyes due to elevated levels of bilirubin in the blood. It is typically associated with liver or gallbladder problems and is not a common symptom of a UTI. Therefore, it is not relevant to consider jaundice in the context of a UTI.
C. Incontinence: Incontinence, or the inability to control urination, can be a symptom of a UTI in toddlers. UTIs can cause irritation of the bladder, leading to urgency, frequency, and in some cases, incontinence. Therefore, incontinence is a relevant finding to consider in the context of a UTI.
D. Rebound tenderness: Rebound tenderness is a sign of peritoneal irritation and is typically associated with conditions affecting the abdomen, such as appendicitis or peritonitis. It is not a typical symptom of a UTI. Therefore, it is not relevant to consider rebound tenderness in the context of a UTI.
Correct Answer is A
Explanation
A. Report of diplopia
Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.
B. Hyperactivity
Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.
C. Nuchal rigidity
Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.
D. Report of sore throat
A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.
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