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 C

Explanation

Choice A reason: Play dates maintain social contact but disrupt the 3-year-old’s preschool routine, which provides stability. Continuing preschool supports normalcy and security, making this less effective and incorrect compared to maintaining the familiar structure of school for a child with leukemia.

Choice B reason: Keeping the child home for one-on-one time may isolate her, reducing social interaction critical for a 3-year-old’s security. Preschool attendance fosters normalcy, making this overly restrictive and incorrect compared to supporting the child’s routine and social needs during leukemia treatment.

Choice C reason: Continuing preschool as much as possible maintains routine and social connections, fostering security for a 3-year-old with leukemia. This aligns with pediatric psychosocial care for chronic illness, making it the correct recommendation to help the child feel secure during her treatment.

Choice D reason: Special family outings are bonding but disrupt the 3-year-old’s preschool routine, which provides consistent security. Continuing school is more stabilizing, making this less consistent and incorrect compared to maintaining the child’s normal preschool environment to support her sense of security.

A. “I always cook foods that are low in fat.” B. “I keep lots of snacks on hand because my child eats all day long.” C. “We eat fast foods only on weekends because we are too busy to cook.” D. “Neither my husband nor I have ever had any concerns with weight.”

Correct Answer is A

Explanation

Choice A reason: Cooking low-fat foods demonstrates a proactive approach to healthy eating, reducing calorie-dense intake and preventing obesity. This aligns with pediatric nutrition guidelines for obesity prevention, making it the best statement indicating caregivers’ preparedness to promote healthy weight in their child during discussions.

Choice B reason: Keeping many snacks encourages frequent eating, potentially high-calorie intake, increasing obesity risk. Low-fat cooking directly addresses dietary quality, making this counterproductive and incorrect compared to a strategy focused on reducing fat content to prevent obesity in school-aged children.

Choice C reason: Limiting fast food to weekends reduces unhealthy intake but does not proactively promote healthy eating like low-fat cooking. Fast food, even occasionally, is high in calories, making this less effective and incorrect for demonstrating optimal preparedness to prevent childhood obesity among caregivers.

Choice D reason: Parental weight history is irrelevant to current actions preventing child obesity. Cooking low-fat foods actively addresses dietary habits, while personal weight concerns do not ensure healthy practices, making this incorrect for illustrating caregivers’ readiness to prevent obesity in their child.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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