A nurse is caring for a school-age child who is experiencing pain. Which of the following assessment techniques will provide the nurse with the most accurate information regarding the child's pain?
Assess the child's pulse and respirations.
Observe the child's facial expressions.
Ask the child to use a FACES rating scale.
Monitor the child's involuntary movements.
The Correct Answer is C
Choice A reason: Assessing the child's pulse and respirations can indicate pain through physiological changes, but these signs can be influenced by other factors and may not provide an accurate measure of pain intensity.
Choice B reason: Observing the child's facial expressions can give some indication of pain, but it is subjective and may not accurately reflect the child's pain experience, especially if the child is trying to hide their discomfort.
Choice C reason: Asking the child to use a FACES rating scale allows the child to actively participate in communicating their pain level. This method is age-appropriate and provides a visual way for children to express the intensity of their pain, making it a reliable assessment technique.
Choice D reason: Monitoring the child's involuntary movements can provide clues about pain, but like facial expressions, they are subjective and may not accurately quantify the child's pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.
Choice B reason: A BUN level of 5 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.
Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.
Choice D reason: A WBC count of 15,000/mm³ is slightly elevated, which may be expected in a child with meningitis as it indicates an immune response to infection. However, it is not as critical as an abnormal creatinine level in the context of gentamicin therapy.
Correct Answer is C
Explanation
Choice A reason: Weight loss is not typically an indication of heart failure. In fact, patients with heart failure may experience weight gain due to fluid retention.
Choice B reason: Decreased respirations are not a common sign of heart failure. Instead, heart failure can cause increased respiratory rate and effort due to fluid accumulation in the lungs.
Choice C reason: Exercise intolerance, or difficulty in engaging in physical activity, is a classic symptom of heart failure. It occurs due to the heart's inability to pump enough blood to meet the body's demands during exercise.
Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct indication of heart failure. While it can be associated with certain cardiac conditions, it is not a specific sign of heart failure.
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