A nurse is caring for a 5 year old and needs to measure their temperature using an electronic oral thermometer. Which intervention will provide the child with an increased sense of control?

Allow the child to hold the thermometer in their mouth until it beeps.

If the child protests tell them you will come back later.

Have the parents wait outside the room.

Ask the child if it is ok to take their temperature.

Answer and Explanation

Correct Answer : A,D

A. Allow the child to hold the thermometer in their mouth until it beeps:

Allowing the child to hold the thermometer can provide a sense of control and involvement in the process. It may help reduce anxiety and make the experience less intimidating for the child. The beeping sound indicates when the temperature measurement is complete.

B. If the child protests, tell them you will come back later:

This choice is not recommended because it ignores the child's immediate needs and concerns. It may increase anxiety or fear, and delaying the process may not be in the best interest of the child's well-being.

C. Have the parents wait outside the room:

While it's common to have parents present during medical procedures for emotional support, in this case, involving the parents may not directly address the child's need for control during the temperature measurement.

D. Ask the child if it is ok to take their temperature:

Asking the child for permission respects their autonomy and involves them in the decision-making process. It promotes a sense of control and may reduce any potential resistance or fear the child might have.

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Correct Answer is D

Explanation

A. The child's current vital signs are consistent with vital signs over the past 4 hours.

Vital signs alone may not be sufficient to assess pain in a child. Children may experience pain without significant changes in vital signs. Behavioral cues and self-reporting are important indicators of pain in pediatric patients.

B. The child becomes quiet when held and cuddled.

While seeking comfort through cuddling may be a sign of distress or discomfort, it is not specific enough to determine the need for pain medication. Additional assessment is required to understand the underlying cause of the child's change in behavior.

C. The child has a temperature of 38.5°C.

Fever alone does not necessarily indicate the need for pain medication. It may suggest an infection or illness, but the specific assessment of pain requires consideration of the child's behavior, verbal expressions, and any other cues related to pain.

D. The child is lying stiffly in bed, not moving, and refusing to get up.

In this scenario, the child's behavior of lying stiffly in bed, not moving, and refusing to get up is indicative of potential pain. Children may express pain in various ways, and behavioral cues such as changes in activity, refusal to move, or guarding certain body parts can suggest discomfort. It is important for the nurse to assess and address the child's pain promptly.

A. Ask the patient to wait a little longer for the medicine to work. B. Review whether the morphine dose is therapeutic for his weight. C. Call the physician immediately. D. Encourage the child to use television as a form of distraction.

Correct Answer is C

Explanation

A. Ask the patient to wait a little longer for the medicine to work.
This option may not be appropriate, especially if the child is experiencing significant pain. It's essential to address the child's pain promptly rather than asking them to wait, as adequate pain management is crucial for the child's well-being.
B. Review whether the morphine dose is therapeutic for his weight.
While reviewing the dose for the child's weight is important, it may not be the immediate next step in this situation. If the child is experiencing pain that persists after one hour, the priority is to address the immediate pain concern. The nurse can later review the medication orders and dosages in collaboration with the healthcare provider.
C. Call the physician immediately.
This is the most appropriate next step in this scenario. If the child is experiencing pain despite having received morphine one hour ago, contacting the physician is important to discuss the current situation, assess the need for additional pain management, and potentially make adjustments to the treatment plan.
D. Encourage the child to use television as a form of distraction.
Distraction can be a helpful complementary measure for managing pain, but it may not be sufficient in this case if the pain persists. The primary focus should be on addressing the pain through appropriate medical interventions, and calling the physician is a more urgent step.

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A nurse is caring for a 5 year old and needs to measure their temperature using an electronic oral thermometer. Which intervention will provide the child with an increased sense of control?

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