When evaluating a terminally ill client for pain relief following medication administration, which nursing assessments would be documented to support that the medication was effective? (Select all that apply)

Heart rate and respirations are within normal limits.

The child is withdrawing from the environment.

The client is lying in a flexed position on the bed.

The client verbalizes a 1 on the analog pain scale.

The client is quietly sleeping on the parent’s lap.

Answer and Explanation

Correct Answer : A,D,E

Choice A reason: Normal heart rate and respirations indicate reduced physiological stress from pain, supporting effective medication in a terminally ill child. This aligns with pediatric pain assessment criteria, making it a correct assessment to document as evidence of successful pain relief post-medication administration.

Choice B reason: Withdrawing from the environment suggests ongoing distress or pain, not relief. Normal vitals and low pain scores indicate effectiveness, making this incorrect, as it reflects a negative outcome rather than supporting successful pain management in the terminally ill child’s evaluation.

Choice C reason: A flexed position may indicate persistent pain or discomfort, not relief. Sleeping or low pain scores better demonstrate effectiveness, making this incorrect, as it does not support the medication’s success in alleviating pain in the terminally ill client during the assessment.

Choice D reason: Verbalizing a 1 on the pain scale directly indicates minimal pain, confirming the medication’s effectiveness in a terminally ill child. This aligns with pediatric pain management standards, making it a correct assessment to document as evidence of successful pain relief post-administration.

Choice E reason: Quietly sleeping on the parent’s lap suggests comfort and pain relief, a positive sign in a terminally ill child. This aligns with behavioral pain assessment in pediatrics, making it a correct observation to document as evidence of effective medication for pain management.

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Correct Answer is A

Explanation

Choice A reason: Burn fluid replacement follows the Parkland formula, with half the total volume (24 ounces = 12 ounces) given in the first 8 hours. From 10:00 AM to 6:00 PM (8 hours), the child receives 12 ounces, aligning with pediatric burn care protocols, making this the correct choice.

Choice B reason: By 4:00 PM (6 hours), the child receives less than half the 24 ounces, as half (12 ounces) is given over 8 hours. The 12-ounce mark is reached by 6:00 PM, making this incorrect, as it overestimates fluid delivery in the shorter timeframe for burn treatment.

Choice C reason: 18 ounces by 4:00 PM (6 hours) exceeds the standard rate, as only half (12 ounces) of 24 ounces is given in 8 hours. The correct amount is 12 ounces by 6:00 PM, making this incorrect for burn fluid replacement timing in the pediatric patient’s treatment.

Choice D reason: 18 ounces by 6:00 PM (8 hours) is incorrect, as only half the total (12 ounces) is administered in the first 8 hours per burn protocols. The correct volume is 12 ounces, making this incorrect for the standard fluid replacement schedule in pediatric burn care.

A. “Try having her eat with the family and she will want what others are eating.” B. “It is important that each time she eats, she has a variety of foods.” C. “Food jags are common in this age. This probably won’t last long.” D. “She should be discouraged from having food likes or dislikes. Have her eat everything.”

Correct Answer is C

Explanation

Choice A reason: Eating with family may encourage variety but does not address the normalcy of food jags in 6-year-olds. Reassuring about their transient nature reduces caregiver stress, making this less direct and incorrect compared to normalizing the child’s selective eating behavior for the concerned caregiver.

Choice B reason: Insisting on variety at every meal may escalate mealtime stress, as food jags are normal and temporary in 6-year-olds. Acknowledging their common occurrence is more supportive, making this pressuring and incorrect for addressing the caregiver’s nutritional concern about the child’s eating habits.

Choice C reason: Food jags, where a child fixates on one food, are common at age 6 and typically resolve naturally. Reassuring the caregiver reduces anxiety and aligns with pediatric nutrition guidance, making this the prioritized response to address concerns about the child’s nutrition and eating patterns.

Choice D reason: Discouraging food preferences risks mealtime conflicts, as food jags are developmentally normal. Normalizing their temporary nature supports the caregiver without forcing the child, making this unhelpful and incorrect compared to reassuring about the common, transient behavior in 6-year-olds.

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When evaluating a terminally ill client for pain relief following medication administration, which nursing assessments would be documented to support that the medication was effective? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The caregiver of a 6-year-old is concerned the child is not getting proper nutrition because on some days, the child will only eat one type of food. Which response should the nurse prioritize for this caregiver?

Correct Answer is C

Explanation

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