A second grader enters the school nurse's office crying and states, "I feel sick. My tummy hurts." The nurse replies, "I'll call your mommy or daddy to come pick you up." The child replies, "I don't have a mommy. I have two daddies." Which of the following comments by the nurse is appropriate?

Of course you have a mommy. You just don't live with your mommy.

It must be interesting to live with two men and no women in the household.

I'll call one of your daddies to come pick you up.

That's right. I forgot your parents are gay.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not appropriate because it denies the child's reality and implies that having two daddies is not normal. It may also hurt the child's feelings and make them feel ashamed of their family.

Choice B reason: This is not appropriate because it sounds judgmental and curious about the child's family structure. It may also make the child feel uncomfortable and different from other children.

Choice C reason: This is appropriate because it accepts the child's statement and shows respect for their family. It also focuses on the child's immediate need and comfort.

Choice D reason: This is not appropriate because it sounds sarcastic and dismissive of the child's family. It may also make the child feel angry and defensive.

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Correct Answer is B

Explanation

Choice A: 0 - This would indicate that the child shows no signs of discomfort or pain. However, the nurse observed an occasional grimace and squirming, tense activity, which are signs of mild discomfort.

Choice B: 1 - This is the correct answer. The FLACC scale assesses five categories: Face, Legs, Activity, Cry, and Consolability, each scored from 0-2. In this case, the child scored 1 for Face (occasional grimace) and 0 for all other categories, totaling a score of 1.

Choice C: 2 - A score of 2 would indicate more signs of discomfort or pain than observed. The child's legs were relaxed, there was no cry, and the child was consolable, which are all scored as 0.

Choice D: 3 - A score of 3 would suggest even more significant signs of discomfort or pain, which is not consistent with the nurse's observations.

A. Get emergency equipment at the bedside. B. Make her lie down and rest quietly. C. Complete a thorough neurological assessment. D. Auscultate her lungs and prepare for administering oxygen.

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because the girl's symptoms indicate that she may have epiglottitis, a life-threatening condition that causes swelling of the epiglottis and obstructs the airway. The nurse should be prepared for a possible intubation or tracheostomy.

Choice B reason: This is not the correct answer because making the girl lie down and rest quietly may worsen her respiratory distress and anxiety. The girl should be allowed to sit in a position of comfort and ease of breathing.

Choice C reason: This is not the correct answer because a thorough neurological assessment is not the priority in this situation. The nurse should focus on the girl's airway, breathing, and circulation.

Choice D reason: This is not the correct answer because auscultating the lungs and preparing for administering oxygen may not be sufficient to manage the girl's airway obstruction. The nurse should also have emergency equipment ready and call for assistance.

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A second grader enters the school nurse's office crying and states, "I feel sick. My tummy hurts." The nurse replies, "I'll call your mommy or daddy to come pick you up." The child replies, "I don't have a mommy. I have two daddies." Which of the following comments by the nurse is appropriate?

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Naxlex Comprehensive Predictor Exams

The nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability: content, relaxed. The nurse records the patient's pain using the FLACC assessment as:

Correct Answer is B

Explanation

A six-year-old girl is brought to the emergency department. She has a "frog-like croaking sound" on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should first do which of the following?

Correct Answer is A

Explanation

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