A nurse is assessing a client's pain using a pain scale. Which pain scale is commonly used for children who are too young to verbalize their pain intensity?

Numeric Rating Scale (NRS)

Visual Analog Scale (VAS)

Faces Pain Scale - Revised (FPS-R)

Wong-Baker FACES Pain Rating Scale

Answer and Explanation

The Correct Answer is D

Answer: c. Faces Pain Scale - Revised (FPS-R) Explanation: The Faces Pain Scale - Revised (FPS-R) is commonly used for children who are too young to verbalize their pain intensity. It consists of a series of faces depicting different levels of pain intensity.

a. The Numeric Rating Scale (NRS) and Visual Analog Scale (VAS) require verbal or numerical expression of pain intensity, which may not be possible for young children.

d. The Wong-Baker FACES Pain Rating Scale is also commonly used for children and includes a series of faces to assess pain intensity, but the FPS-R is more widely used.

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Correct Answer is C

Explanation

Answer: c. Swipe the thermometer gently across the client's forehead.

Explanation: Temporal artery thermometers are used by swiping the thermometer gently across the client's forehead. The device measures the temperature of the temporal artery, which correlates with core body temperature.

a. Inserting the thermometer into the rectum is not the appropriate method for using a temporal artery thermometer.

b. Placing the thermometer in the axilla is appropriate for axillary temperature measurement but not for temporal artery thermometers.

d. Holding the thermometer under the tongue is appropriate for oral temperature measurement but not for temporal artery thermometers.

A. Administer oxygen via a nasal cannula. B. Place the client in a supine position. C. Reassess the respiratory rate after 1 hour. D. Perform a thorough respiratory assessment.

Correct Answer is D

Explanation

Explanation: A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths per minute), indicating potential respiratory distress. The nurse should perform a thorough respiratory assessment to gather more information and determine appropriate interventions.

a. Administering oxygen may be necessary, but the nurse should first assess the client's respiratory status before initiating any interventions.

b. Placing the client in a supine position is not indicated and may worsen respiratory distress in some situations.

c. Reassessing after 1 hour is not appropriate when a client is experiencing abnormal vital signs; immediate action is needed.

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A nurse is assessing a client's pain using a pain scale. Which pain scale is commonly used for children who are too young to verbalize their pain intensity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's body temperature using a temporal artery thermometer. How should the nurse use the temporal artery thermometer?

Correct Answer is C

Explanation

A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take first?

Correct Answer is D

Explanation

A nurse is assessing a client's oxygen saturation level using a pulse oximeter. Which oxygen saturation level indicates the need for immediate intervention?

A nurse is assessing a client's blood pressure and finds a significant difference between the blood pressure readings in the client's right and left arms. What action should the nurse take?

A nurse is assessing a client's vital signs. Which vital sign reflects the number of times the heart beats per minute?

During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?

A nurse is assessing a client's blood pressure using a manual sphygmomanometer and a stethoscope. What action should the nurse take to obtain an accurate blood pressure reading?

A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?

A nurse is assessing a client's pain using a pain scale. Which pain scale is commonly used for children who are too young to verbalize their pain intensity?