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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. New heart murmur

This is a common finding in infective endocarditis due to damage to the heart valves caused by the infection. The infection can lead to the development of new heart murmurs or changes in existing ones as the valves become affected.

B. Weight gain

Weight gain is not typically associated with infective endocarditis. In fact, individuals with infective endocarditis may experience weight loss due to symptoms such as fever, loss of appetite, and malaise.

C. Bradycardia

Bradycardia, or a slow heart rate, is not a typical finding in infective endocarditis. In many cases, individuals with infective endocarditis may actually present with tachycardia (rapid heart rate) due to fever and the body's response to infection.

D. Decreased body temperature

Infective endocarditis is often associated with fever, which would lead to an elevated body temperature rather than a decreased one.

A. Administer packed red blood cells transfusion (PRBC) B. Avoid taking rectal temperatures C. Place child in protective environment precautions D. Swab the oral cavity with viscous lidocaine

Correct Answer is B

Explanation

A. Administer packed red blood cells transfusion (PRBC):

While anemia may also be a concern in leukemia, the primary issue here is thrombocytopenia, not anemia. Administering packed red blood cells transfusion would address anemia, not the low platelet count.

B. Avoid taking rectal temperatures:

This is the correct option. Taking rectal temperatures carries the risk of causing bleeding or trauma, especially in individuals with thrombocytopenia. It is essential to avoid invasive procedures or activities that may increase the risk of bleeding in a patient with a low platelet count.

C. Place child in protective environment precautions:

Protective environment precautions, also known as reverse isolation, are typically implemented for patients who are immunocompromised to protect them from exposure to infectious agents. While patients with leukemia may be immunocompromised, the low platelet count is the primary concern here, not infection risk.

D. Swab the oral cavity with viscous lidocaine:

Swabbing the oral cavity with viscous lidocaine is not indicated for thrombocytopenia. Lidocaine may have local anesthetic properties but does not address the underlying issue of low platelet count.

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A nurse is assessing a 4-year-old child following a surgical procedure. Which of the following pain rating scales should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a toddler who has infective endocarditis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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