The nurse is caring for a child with multiple injuries following a motor vehicle accident. According to the QUESTT pain assessment, what are the two first steps the nurse should take in evaluating the child's pain?
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for Correct Choices:
• Question the child: This is the initial and most direct step in pain assessment, as it gathers first-hand information from the child about the nature, location, and intensity of pain. It respects the child’s ability to self-report and guides further evaluation. Asking the child sets the foundation for a tailored pain management plan.
• Evaluate behavior and physiological changes: Observing behavioral cues (such as crying, guarding, or restlessness) and physiological indicators (like pallor or sweating) provides critical information, especially when the child has difficulty communicating. This is the second essential step in the QUESTT framework to assess pain objectively.
Rationale for Incorrect Choices:
• Use a pain scale: Using a pain scale is important to quantify pain, but it typically follows the initial questioning. Without first engaging the child to understand their pain experience, the scale may be less accurate or meaningful. Pain scales help track changes over time but are not the very first step.
• Examine the injury site: Physical examination of the injury site helps identify the possible source of pain and assess severity. However, this comes after the child’s subjective report and should be part of a comprehensive assessment rather than the initial step. It may also cause discomfort if done too early without preparation.
• Take vital signs: Vital signs can reflect physiological responses to pain such as increased heart rate or blood pressure, but these signs are nonspecific and can be influenced by many factors. They supplement the pain assessment but do not replace direct questioning or behavioral observation.
• Administer pain medication: Providing pain relief is vital but should only be done after a thorough pain assessment to ensure appropriate dosing and timing. Administering medication before understanding the pain risks ineffective or unsafe treatment.
• Ask the parents about the child’s pain: Parents can offer valuable insights into the child’s typical pain behaviors and history. However, parent reports are supplementary and should not replace the child’s own description or the nurse’s observations. The child’s perspective remains primary.
• Reassess pain after intervention: Reassessment is critical to evaluate the effectiveness of pain management strategies. However, it only occurs after initial assessment and treatment, making it a later step in the pain management process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Encourage activity to prevent atelectasis: Early activity is not advised immediately after a cardiac catheterization because movement can disrupt the clot at the insertion site, increasing the risk of bleeding or hematoma formation. The child should be kept on bed rest with the affected limb straight for the recommended period.
B. Monitor skin color and temperature of the surgical limb: This is important to assess for adequate circulation to the limb after catheterization. A change in color or temperature may indicate compromised blood flow or vascular injury, which requires immediate attention.
C. Check the brachial pulse closest to the surgical site: For a cardiac catheterization, the insertion site is usually in the femoral artery or vein. Checking a brachial pulse would not give relevant information about perfusion in the affected extremity.
D. Check the pulse distal to the surgical site: Distal pulses, such as the dorsalis pedis or posterior tibial pulse if the femoral site was used, are essential to assess for vascular compromise following catheterization.
E. Monitor for bleeding and drainage from the site: The catheterization site must be closely observed for any bleeding, swelling, or drainage. Even small amounts of bleeding can be significant in an infant and should be addressed immediately.
F. Maintain NPO precautions and reduce fluid intake: Unless there are complications affecting feeding or consciousness, the child can resume fluids and feeds as ordered. Fluid restriction is not routine after cardiac catheterization unless specifically indicated by the provider.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
Rationale:
• Hypoplastic Left Heart Syndrome is cyanotic because severe underdevelopment of the left heart structures leads to mixing of oxygenated and deoxygenated blood, causing systemic hypoxemia from birth.
• Transposition of the Great Arteries is cyanotic as the aorta and pulmonary artery are switched, creating two separate circulations where oxygenated blood does not reach the systemic circulation without a shunt.
• Atrial Septal Defect is acyanotic because it initially causes a left-to-right shunt, increasing pulmonary blood flow without significant desaturation until later complications develop.
• Coarctation of the Aorta is acyanotic since it involves narrowing of the aorta, leading to obstruction of blood flow rather than abnormal mixing, so oxygen saturation typically remains normal.
• Patent Ductus Arteriosus is acyanotic in early stages because blood flows from the higher-pressure aorta into the pulmonary artery, increasing pulmonary circulation without systemic desaturation.
• Tetralogy of Fallot is cyanotic due to the combination of four defects, including right ventricular outflow obstruction, which forces deoxygenated blood into the systemic circulation.
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