A six-year-old complains of pain at the surgical site, one hour after the nurse gave IV morphine, which is ordered every four hours prn pain. What is the nurse's best next step?
Ask the patient to wait a little longer for the medicine to work.
Review whether the morphine dose is therapeutic for his weight.
Call the physician immediately.
Encourage the child to use television as a form of distraction.
The Correct Answer is C
A. Ask the patient to wait a little longer for the medicine to work.
This option may not be appropriate, especially if the child is experiencing significant pain. It's essential to address the child's pain promptly rather than asking them to wait, as adequate pain management is crucial for the child's well-being.
B. Review whether the morphine dose is therapeutic for his weight.
While reviewing the dose for the child's weight is important, it may not be the immediate next step in this situation. If the child is experiencing pain that persists after one hour, the priority is to address the immediate pain concern. The nurse can later review the medication orders and dosages in collaboration with the healthcare provider.
C. Call the physician immediately.
This is the most appropriate next step in this scenario. If the child is experiencing pain despite having received morphine one hour ago, contacting the physician is important to discuss the current situation, assess the need for additional pain management, and potentially make adjustments to the treatment plan.
D. Encourage the child to use television as a form of distraction.
Distraction can be a helpful complementary measure for managing pain, but it may not be sufficient in this case if the pain persists. The primary focus should be on addressing the pain through appropriate medical interventions, and calling the physician is a more urgent step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Magical thinking
Magical thinking is a cognitive characteristic commonly observed in preschool-aged children. It involves believing that one's thoughts, wishes, or actions can influence events, even when there is no logical or causal connection. For example, a preschooler might believe that simply thinking about a toy can make it appear.
B. Thoughts are all-powerful
The belief that thoughts have omnipotent power is often seen in the preoperational stage of cognitive development, which occurs in early childhood. Children in this stage may think that their thoughts alone can cause significant changes or events.
C. Ability to conserve
Conservation is a cognitive skill associated with the concrete operational stage of development, typically occurring around 7 to 11 years of age. Children at this stage understand that certain properties of objects remain the same despite changes in appearance. For example, they recognize that the amount of liquid stays the same when poured into a differently shaped container.
D. Animism
Animism is a concept observed in the preoperational stage, where children attribute life-like qualities to inanimate objects. For instance, a child might believe that a stuffed animal has feelings or thoughts.
Correct Answer is B
Explanation
A. Child Abuse
While the presence of welts might be concerning, it is essential for the nurse to consider cultural practices before labeling the situation as child abuse. In this case, the coin rubbing is described as a cultural practice rather than an abusive act.
B. A cultural practice to rid the body of disease.
This is the correct choice. Coin rubbing, or "coining," is a cultural practice in some traditions, including Vietnamese culture. It is believed to have therapeutic benefits and is used to address health concerns.
C. A child discipline measure common in Asian cultures.
The scenario does not provide evidence that the coin rubbing is a form of discipline. It seems to be described as a traditional health practice rather than a disciplinary measure.
D. A cultural practice to treat temper tantrums.
The scenario does not indicate that the coin rubbing is related to treating temper tantrums. It appears to be described as a health-related cultural practice rather than a disciplinary measure.
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