A nurse is planning to assess a 10 month-old infant and bases the assessment on which rationale?

Begin with taking all the vital signs.

Use the Faces scale to rate their pain

Start with less intrusive methods.

Be systematic and go in head to toe order.

Answer and Explanation

The Correct Answer is C

A. Begin with taking all the vital signs.

This is not the preferred approach for assessing a 10-month-old infant. Vital signs may be intimidating and intrusive, and starting with less invasive methods is generally recommended.

B. Use the Faces scale to rate their pain.

The Faces scale is typically used for older children who can express themselves verbally. It may not be suitable for a 10-month-old infant.

C. Start with less intrusive methods.

This is the correct choice. Beginning with less intrusive methods, such as observation and gentle interactions, helps build trust and ensures the infant is comfortable during the assessment.

D. Be systematic and go in a head-to-toe order.

While being systematic is important, starting with less intrusive methods and adapting the approach based on the infant's response is generally more appropriate than a strict head-to-toe order.

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Correct Answer is B

Explanation

A. FACES
The FACES scale, often depicted with a series of faces displaying different expressions, is commonly used for children who can understand and respond to a scale of faces indicating different levels of pain. It is suitable for older children who can articulate their feelings.

B. FLACC
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is commonly used to assess pain in preverbal and non-verbal children, such as a 4-year-old. It evaluates the child's facial expression, leg movement, activity level, cry, and ease of consolability to determine the level of pain.
C. APPT
There is no widely recognized pain assessment tool referred to as "APPT." It may be a term specific to a certain context or institution.

D. Numeric
Numeric pain scales involve asking individuals to rate their pain on a numerical scale, usually ranging from 0 to 10. These scales are often used with older children and adults who can understand and communicate numerical values to describe their pain intensity.

A. Bronchiolitis B. Pharyngitis C. Asthma D. Cystic Fibrosis

Correct Answer is D

Explanation

A. Bronchiolitis:
Bronchiolitis is typically characterized by inflammation of the bronchioles, causing symptoms such as wheezing and respiratory distress. However, the symptom of tasting salt on the skin is not directly associated with bronchiolitis.

B. Pharyngitis:
Pharyngitis, or inflammation of the throat, may cause symptoms like a sore throat, but it is not typically associated with a salty taste on the skin.

C. Asthma:
Asthma is a chronic condition characterized by airway inflammation and bronchoconstriction. While it can cause respiratory symptoms, it is not specifically associated with a salty taste on the skin.

D. Cystic Fibrosis:
Cystic Fibrosis is a genetic disorder that affects the respiratory, digestive, and reproductive systems. It often leads to salty-tasting skin due to increased salt content in sweat. The presence of a salty taste on the skin can be a significant indicator of cystic fibrosis.

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A nurse is planning to assess a 10 month-old infant and bases the assessment on which rationale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a 4 year old, the nurse uses which tool to assess pain?

Correct Answer is B

Explanation

The parents of a child, who has had multiple respiratory infections since birth tells the nurse, "when we kiss our child, all we can taste is salt". It would be appropriate for the nurse to suggest to the primary health-care provider that the child be assess for which of the following illnesses?

Correct Answer is D

Explanation

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The nurse observes some children in the playroom. Which play situation exhibits the characteristics of parallel play?

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Which assessment indicates to a nurse that a school-age child is in need of pain medication?

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