A nurse is contributing to the plan of care for a preschooler who is experiencing acute pain from a recent injury. The child describes the pain as "achy". Which of the following interventions should the nurse recommend? (Select All that Apply)

Activity

Warm compress

Opioids

Acetaminophen

Guided imagery

High protein diet

Answer and Explanation

Correct Answer : B,D,E

A. Activity. Encouraging physical activity is not appropriate for a preschooler experiencing acute pain, as movement may worsen discomfort or delay healing. Rest is often more beneficial in managing pain from an injury.

B. Warm compress. A warm compress can help relieve muscle tension and improve blood flow, reducing pain perception in certain injuries, such as sprains or muscle aches. It is a safe and effective non-pharmacological intervention for preschoolers.

C. Opioids. Opioids are not the first-line treatment for mild to moderate acute pain in children due to the risk of side effects such as respiratory depression and dependence. Less potent pain management options should be used first.

D. Acetaminophen. Acetaminophen is a safe and effective analgesic for managing mild to moderate pain in children. It helps reduce discomfort and is commonly used for injuries, fevers, and post-procedural pain.

E. Guided imagery. Guided imagery is a distraction technique that can help preschoolers manage pain by shifting focus away from discomfort. Simple visualizations, like imagining a favorite place or a comforting scenario, can be effective.

F. High protein diet. While a high-protein diet supports tissue healing, it does not provide immediate pain relief. Nutritional support is important for recovery but is not a direct intervention for acute pain management.

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Correct Answer is B

Explanation

A. Presence of Dance sign. Dance sign (an empty right lower quadrant on palpation) is associated with intussusception, not pyloric stenosis. Pyloric stenosis is characterized by hypertrophy of the pyloric sphincter, leading to gastric outlet obstruction.

B. Projectile vomiting. Forceful, non-bilious projectile vomiting is the hallmark symptom of pyloric stenosis. It occurs due to the narrowing of the pyloric sphincter, preventing stomach contents from passing into the small intestine. Vomiting usually begins around 2 to 6 weeks of age and worsens over time.

C. Always seems full. Infants with pyloric stenosis actually experience hunger and irritability after vomiting because food is not reaching the intestines for digestion and absorption.

D. Excessive weight gain. Instead of gaining weight, infants with pyloric stenosis often experience weight loss or poor weight gain due to repeated vomiting and inadequate nutrient absorption.

A. Changes in feeding and bowel habits. B. Presence of a single palmar crease on the child's hands. C. Height and weight measurement below the 50th percentile for their age. D. Evaluation of the caregiver's financial resources.

Correct Answer is A

Explanation

A. Changes in feeding and bowel habits. In children with Down syndrome, sudden changes in feeding and bowel habits can indicate serious conditions such as gastrointestinal obstruction (e.g., Hirschsprung’s disease) or hypothyroidism. These conditions require immediate follow-up as they can lead to complications like malnutrition or bowel obstruction.

B. Presence of a single palmar crease on the child's hands. A single transverse palmar crease (simian crease) is a common physical feature in Down syndrome but is not an urgent concern. It does not require immediate medical intervention.

C. Height and weight measurement below the 50th percentile for their age. Children with Down syndrome often have shorter stature and lower weight percentiles due to their genetic condition. While growth monitoring is important, it is not an immediate concern unless severe failure to thrive is present.

D. Evaluation of the caregiver's financial resources. Assessing financial resources is important for long-term care planning, but it does not require urgent medical intervention. Immediate follow-up should prioritize health concerns affecting the child’s well-being.

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A nurse is contributing to the plan of care for a preschooler who is experiencing acute pain from a recent injury. The child describes the pain as "achy". Which of the following interventions should the nurse recommend? (Select All that Apply)

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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