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 D
Explanation
Rationale:
A. Girls have a smaller bladder size than boys do: Bladder size does not significantly differ between boys and girls in a way that increases UTI risk. The primary causes of higher UTI incidence in girls are anatomical and related to bacterial access to the urinary tract.
B. Her kidneys are less well protected: Kidney protection is generally similar between boys and girls, and kidney anatomy does not explain the higher UTI rates in females. UTIs usually originate from ascending infections, not direct kidney vulnerability.
C. A girl's urethra is longer than a boy's urethra: This is the opposite of the truth. Girls actually have a much shorter urethra, which makes it easier for bacteria to travel from the perineum to the bladder, increasing infection risk.
D. A girl's urethra is closer to the rectal opening: This proximity makes it easier for bacteria, especially E. coli from the gastrointestinal tract, to reach the urethra. Combined with the short length of the female urethra, this anatomical factor is the main reason why girls experience UTIs more frequently than boys.
Correct Answer is ["A","D","E","G"]
Explanation
Rationale:
A. Metformin twice a day, taken with food to prevent GI upset: Metformin is the first-line medication for Type 2 Diabetes and helps improve insulin sensitivity. Taking it with food reduces gastrointestinal side effects, making this a key part of treatment.
B. Long acting lantus before bed to control blood sugar overnight: While insulin may be necessary in some Type 2 Diabetes cases, especially with significant hyperglycemia, it is not typically the initial treatment for newly diagnosed adolescents. It is more common in Type 1 Diabetes or advanced Type 2.
C. Rapid Acting Insulin dosed using a sliding scale before every meal: Sliding scale insulin is generally reserved for Type 1 Diabetes or severe cases of Type 2 Diabetes with uncontrolled glucose. It is not the standard initial treatment in newly diagnosed Type 2 adolescents.
D. Consistent aerobic exercise every day with a goal of 60 minutes per day: Regular physical activity is essential in managing Type 2 Diabetes as it improves insulin sensitivity and aids in weight management.
E. Regular blood sugar monitoring throughout the day: Monitoring blood glucose levels helps track the effectiveness of treatment and guides lifestyle or medication adjustments in Type 2 Diabetes management.
F. Use of a continuous subcutaneous insulin pump to control blood sugar: Insulin pumps are typically used for Type 1 Diabetes. Their use in Type 2 Diabetes is rare and usually reserved for specific cases, not standard treatment.
G. Well balanced diet and monitoring simple sugar intake: Dietary management focusing on balanced nutrition and limiting simple sugars is fundamental in controlling Type 2 Diabetes and preventing glucose spikes.
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