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 D

Explanation

A. Two 2-1/2 year old children are playing with trucks next to each other but not interacting.

This situation describes parallel play, where children play alongside each other without direct interaction. It's typical in toddlers.

B. Six 8-year-old children are playing kickball at recess.

This situation describes a group engaging in a physical activity (kickball). It doesn't specifically represent associative play, which involves more interaction between children.

C. A 9-month-old infant is shaking a rattle their father hands to them.

This scenario represents a form of solitary play, as the infant is playing alone with the rattle.

D. Two 4-year-old children are playing house together.

This situation describes associative play. In associative play, children engage in similar or identical activities without rigid organization or rules. In this case, the children are playing house together, involving some interaction.

A. Perform passive range of motion on the injured knee. B. Put an ice pack on the child's knee. C. Have the child watch a favorite program on television. D. Read a book to the child.

Correct Answer is ["B","C","D"]

Explanation

A. Perform passive range of motion on the injured knee.

While passive range of motion exercises can be beneficial in some situations, it's important to exercise caution, especially with an injured knee. Without detailed information about the nature and extent of the injury, manipulating the injured area could potentially worsen the pain or cause harm. It is advisable to consult with the healthcare provider before implementing passive range of motion exercises.

B. Put an ice pack on the child's knee.

Applying an ice pack is a nonpharmacological intervention that can help reduce inflammation and provide pain relief for certain types of injuries. It is commonly used in the management of acute injuries to minimize swelling and alleviate discomfort.

C. Have the child watch a favorite program on television.

Distraction is an effective nonpharmacological approach to pain management, especially in children. Allowing the child to engage in a favorite activity, such as watching a program on television, can divert their attention from the pain and contribute to their overall well-being.

D. Read a book to the child.

Reading a book is a comforting and distracting activity. It creates a positive and calming environment, and it can help shift the child's focus away from the pain. This nonpharmacological intervention promotes a sense of comfort and reassurance.

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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

A nurse is observing children at play. Which situation depicts associative play?

Correct Answer is D

Explanation

To enhance the effectiveness of the pharmacological pain intervention administered to a 4-year old child with an injured knee, the nurse plans to add a nonpharmacological intervention. Which of the following actions would be appropriate for the nurse to perform? (select all that apply)

Correct Answer is ["B","C","D"]

Explanation

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The father of a hospitalized child tells the nurse, "He can't have meat. We are Buddhist and vegetarians." The nurse's best intervention is to:

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When assessing a child's pain, the best approach is for the nurse to:

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