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?

Choice A reason: This is not the correct instruction to include in the discharge teaching. Perform clean intermittent catheterization every 8 hours is a possible intervention for infants who have neurogenic bladder dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require catheterization. The nurse should assess the infant’s bladder function and teach the guardian how to perform catheterization if needed.

Choice B reason: This is not the correct instruction to include in the discharge teaching. Use a rectal thermometer to stimulate the passage of stool twice per day is a possible intervention for infants who have neurogenic bowel dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require rectal stimulation. The nurse should assess the infant’s bowel function and teach the guardian how to manage constipation or fecal incontinence if needed.

Choice C reason: This is not the correct instruction to include in the discharge teaching. Anticipate gradual loss of function in the lower extremities is a possible outcome for infants who have myelomeningocele repair, depending on the location and severity of the defect. However, the nurse should not assume that the infant will lose function in the lower extremities. The nurse should monitor the infant’s motor and sensory development and provide appropriate interventions to promote mobility and prevent complications.

Choice D reason: This is the correct instruction to include in the discharge teaching. Check toys and pacifiers for the presence of latex is an important precaution for infants who have myelomeningocele repair, as they are at risk of developing latex allergy due to repeated exposure to latex products during surgery and medical procedures. The nurse should teach the guardian how to identify and avoid latex-containing items and how to recognize and treat signs of allergic reaction.

Choice A reason: Emotional separation from parents is a part of the normal individuation process that occurs during adolescence, but it is not as immediate or noticeable as mood swings during early adolescence.

Choice B reason: Mood swings are common during early adolescence due to hormonal changes and the development of the child's identity. This can result in rapid and intense emotional responses to situations.

Choice C reason: Increased self-esteem is a possible outcome of successful navigation through adolescence, but it is not guaranteed and is not a characteristic that can be expected to manifest uniformly during early adolescence.

Choice D reason: A decelerating growth rate is more characteristic of late adolescence after the major growth spurts have occurred. Early adolescence is typically a time of continued growth and development.