The nurse is assessing a 7-year-old post-surgery. Despite denying pain, the nurse observes the patient's fists are clenched and forehead is wrinkled. How will the nurse intervene?

Call the healthcare provider.

Wait for the patient to report pain.

Administer intravenous morphine.

Instruct the parent to play relaxing music.

Answer and Explanation

The Correct Answer is C

Choice A reason: Calling the healthcare provider is a valid action if the nurse encounters an unexpected issue or an emergency. However, in this situation, the nurse's immediate observation of physical signs indicating pain suggests that the patient might be experiencing discomfort. The nurse has enough clinical judgment to address the pain directly rather than waiting for a healthcare provider's intervention, which could delay relief.

Choice B reason: Waiting for the patient to report pain is not an ideal choice here because children, especially younger ones, may not always verbalize their pain even when they are in discomfort. The nurse's role involves assessing both verbal and non-verbal cues to provide timely and appropriate care. Physical signs such as clenched fists and a wrinkled forehead strongly indicate pain, necessitating prompt action rather than waiting.

Choice C reason: Administering intravenous morphine is the appropriate intervention given the clear physical signs of pain observed by the nurse. Morphine is a powerful opioid analgesic used to manage moderate to severe pain. In a post-surgical context, controlling pain effectively is crucial for the patient's recovery. Therefore, this action aligns with the need for timely pain management to ensure the child's comfort and facilitate healing.

Choice D reason: Instructing the parent to play relaxing music can be a helpful non-pharmacological intervention to provide a calming environment for the child. However, this action alone is unlikely to address the acute pain suggested by the patient's physical signs. While it can be part of a comprehensive pain management plan, the primary approach should be administering medication to relieve the immediate pain.

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Correct Answer is B

Explanation

Choice A reason: Requesting an enteral tube is not necessary unless the child is unable to eat orally at all. The goal is to support the child's ability to eat independently, if possible.

Choice B reason: Providing large, padded utensils can help a child with cerebral palsy improve their ability to eat independently. Adaptive utensils are designed to accommodate the motor challenges that children with cerebral palsy may face, making it easier for them to grasp and use the utensils.

Choice C reason: While having the parents feed the child can be a short-term solution, it does not promote independence. The focus should be on finding ways to support the child's ability to eat on their own.

Choice D reason: Referring the patient to a nutritionist can be helpful for overall dietary management, but it does not directly address the immediate issue of the child's difficulty with using regular utensils. Adaptive utensils are a more direct solution to this problem.

A. Vaginal delivery after 12 hours of Labor B. Primiparity delivered at 10 cm dilation C. Manual extraction of the placenta

Correct Answer is C

Explanation

Choice A reason: Vaginal delivery after 12 hours of Labor, while potentially exhausting for the mother, does not inherently place her at a higher risk for postpartum haemorrhage compared to other factors. Prolonged Labor can be associated with certain complications, but it is not the most direct indicator of increased haemorrhage risk in the postpartum period.

Choice B reason: Primiparity, or being a first-time mother, delivered at full dilation of 10 cm is a normal part of the childbirth process. While first-time mothers might experience longer Labor durations, this alone does not signify a higher risk for postpartum haemorrhage. Risk factors for haemorrhage typically involve conditions or interventions that impact the uterus's ability to contract effectively after birth.

Choice C reason: Manual extraction of the placenta is a significant risk factor for postpartum haemorrhage. When the placenta does not detach and deliver on its own, manual removal is necessary, which can cause trauma to the uterus and interfere with its ability to contract properly after delivery. The lack of effective uterine contraction can lead to increased bleeding, making this a higher risk scenario for postpartum haemorrhage.

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The nurse is assessing a 7-year-old post-surgery. Despite denying pain, the nurse observes the patient's fists are clenched and forehead is wrinkled. How will the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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