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. Weight gain:
Weight gain is not typically associated with vasoocclusive crisis in sickle cell anemia. In fact, individuals may experience dehydration and weight loss due to increased metabolic demands during a crisis.
B. Bradypnea:
Bradypnea, or slow breathing, is not a characteristic feature of vasoocclusive crisis in sickle cell anemia. Respiratory rate may be normal or increased due to pain or compensatory mechanisms.
C. Pain:
This is the correct option. Pain is the hallmark manifestation of vasoocclusive crisis in sickle cell anemia. The pain can occur anywhere in the body but most commonly affects the bones, joints, abdomen, and chest. The severity of pain can vary from mild to severe and may require hospitalization for pain management.
D. Diarrhea:
Diarrhea is not typically associated with vasoocclusive crisis in sickle cell anemia. Gastrointestinal symptoms such as abdominal pain and nausea may occur, but diarrhea is not a common manifestation of vasoocclusive crisis.
Correct Answer is A
Explanation
A. Obtain a daily weight:
This is an appropriate action. Monitoring daily weights can help assess fluid balance and detect fluid retention, which is common in children with kidney disorders like acute glomerulonephritis. Sudden weight gain or fluid overload may indicate worsening kidney function and the need for intervention.
B. Strain the urine:
Straining the urine may be indicated to monitor for the presence of blood or protein, which are common findings in acute glomerulonephritis. Straining the urine is not necessary, as hematuria is a common finding and does not indicate kidney damage.
C. Monitor blood glucose level every 4 hr:
Monitoring blood glucose levels every 4 hours is not directly related to the care of a child with acute glomerulonephritis. Blood glucose monitoring is more relevant in conditions such as diabetes mellitus. However, monitoring electrolyte levels, including blood glucose, may be part of routine laboratory testing in children with kidney disorders.
D. Recommend strict bed rest:
Strict bed rest is not typically recommended for children with acute glomerulonephritis unless there are specific complications or severe symptoms requiring immobilization. While some activity restriction may be recommended during the acute phase of the illness, strict bed rest may lead to complications such as deconditioning and venous thromboembolism.
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