A nurse is caring for a six-year-old child who had surgery that morning.
The child is awake and lying very still in bed.
What should the nurse do?
Use an “ouch” scale for pain assessment.
Encourage the child to request pain medication when needed.
Plan to administer pain medication if the child begins to cry.
Ask the child to rate their pain on a scale of 1 to 10.
The Correct Answer is A
Choice A rationale
Using an “ouch” scale, such as the Wong-Baker FACES Pain Rating Scale, is appropriate for young children. It allows them to express their pain intensity in a way that is understandable and relatable to their age group.
Choice B rationale
Encouraging a six-year-old to request pain medication may not be effective, as they might not understand when they need it or might be reluctant to ask.
Choice C rationale
Waiting to administer pain medication until the child begins to cry can delay pain relief, leading to unnecessary discomfort and anxiety.
Choice D rationale
Asking a young child to rate their pain on a scale of 1 to 10 might be confusing and less effective than using a more child-friendly method like the “ouch” scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Deoxygenated blood from the lungs would not flow to the left atrium or through the pulmonary artery.
Choice B rationale
Deoxygenated blood from the lungs would not enter the right atrium or flow through the pulmonary artery.
Choice C rationale
Oxygenated blood from the lungs does not enter the right atrium through the pulmonary veins.
Choice D rationale
Correct, oxygenated blood from the lungs enters the left atrium through the pulmonary veins.
Correct Answer is D
Explanation
Choice A rationale
Coagulation studies assess the blood's ability to clot and are not directly related to the monitoring of phenytoin therapy. These tests are more relevant for patients with bleeding disorders or those on anticoagulant therapy.
Choice B rationale
Serum electrolytes, including levels of sodium, potassium, and calcium, are important for overall health but are not specifically indicative of phenytoin levels. Phenytoin may affect calcium metabolism, but it is not the primary focus for routine monitoring.
Choice C rationale
Renal function tests are crucial for assessing kidney function but do not directly monitor phenytoin therapy. Phenytoin is primarily metabolized in the liver, making liver function tests more relevant.
Choice D rationale
Blood glucose levels should be monitored in patients taking phenytoin as the drug can cause alterations in blood glucose levels. Both hypoglycemia and hyperglycemia have been reported, so it is important to check glucose levels to ensure they remain within a normal range.
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