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. Warm the medication container for 10 seconds in a microwave oven prior to instillation. Using a microwave to warm ear drops is unsafe, as it can cause uneven heating and potentially burn the delicate ear structures. Instead, the medication should be warmed by holding the container in the hands for a few minutes.

B. Apply clean gloves and clean the outer ear prior to instilling drops. Wearing gloves prevents contamination, and cleaning the outer ear removes purulent drainage, ensuring the medication reaches the ear canal properly. This is an essential step in infection control and medication effectiveness.

C. Firmly push a cotton ball into the ear canal after instilling drops. Inserting a cotton ball too firmly can trap moisture and bacteria, potentially worsening the infection. If needed, a loosely placed cotton ball may be used, but it should not be forced into the canal.

D. Pull the child's ear auricle upward and outward just before instilling drops. This technique is used for adults and children over 3 years old. In a 2-year-old, the correct method is to pull the auricle downward and back to straighten the ear canal for proper medication administration.

A. Presence of Dance sign B. Projectile vomiting C. Always seems full D. Excessive weight gain

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.

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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)

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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