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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: While exposure to secondhand smoke is unhealthy and should be avoided, it is not commonly listed as a trigger for seizures. The primary concern with secondhand smoke is its impact on respiratory health.
Choice Breason: A prolonged headache can be a symptom of various conditions, but it is not generally considered a direct trigger for seizures. However, if a headache is related to a neurological condition, it may be associated with an increased risk of seizures.
Choice Creason: Decreased temperature, or being cold, is not typically a trigger for seizures. Seizure triggers are usually related to changes in the body's internal environment or external stimuli that affect the nervous system.
Choice D reason: Inadequate sleep is a well-known trigger for seizures. Sleep deprivation can lead to increased seizure activity in individuals with seizure disorders. Ensuring adequate and regular sleep is an important part of managing seizure disorders.
Correct Answer is B
Explanation
Choice A reason: Teaching the child about cast care is important, but it is not the first action to take. Education on cast maintenance and activity restrictions will follow after addressing immediate needs.
Choice B reason: Administering pain medication should be the first action taken by the nurse. After a cast application for a fracture, the child is likely experiencing pain, and managing this pain is a priority to ensure comfort and facilitate healing.
Choice C reason: Elevating the child's leg is a subsequent action that can help reduce swelling and discomfort, but it is not the first action to take. Pain management is the priority before positioning.
Choice D reason: Petaling the edges of the cast, which involves placing soft material around the rough edges to prevent skin irritation, is important but not the first action. The initial focus should be on pain relief.
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