Which assessment indicates to a nurse that a school-age child is in need of pain medication?
The child's current vital signs are consistent with vital signs over the past 4 hours.
The child becomes quiet when held and cuddled.
The child has just returned from the recovery room.
The child is lying rigidly in bed and not moving.
The Correct Answer is D
Choice A reason: The child's current vital signs are not a reliable indicator of pain, as they may vary depending on the child's condition, medication, and stress level. Vital signs alone are not sufficient to assess pain in children.
Choice B reason: The child becoming quiet when held and cuddled may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain. In fact, some children may become more vocal and restless when they are in pain.
Choice C reason: The child having just returned from the recovery room does not necessarily mean that the child is in pain. The child may have received pain medication during or after the surgery, or the child may have a different pain threshold. The nurse should not assume that the child is in pain based on the procedure alone.
Choice D reason: The child lying rigidly in bed and not moving is a sign of pain in children, as they may try to avoid movement that could aggravate their pain. The child may also exhibit facial expressions, such as grimacing, frowning, or clenching their teeth, that indicate pain. The nurse should assess the child's pain level and administer pain medication as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because infant bones are not prone to fractures. They are more flexible and resilient than adult bones, and require more force to break.
Choice B reason: This is not the correct answer because the focus should not be only on the injury, but also on how it occurred. The nurse should assess the mechanism of injury and the history of the child and the family for any signs of abuse or neglect.
Choice C reason: This is the correct answer because inconsistencies in how injury occurred may indicate child maltreatment. The nurse should be alert for any discrepancies or changes in the story, or any explanations that do not match the type or severity of the injury.
Choice D reason: This is not the correct answer because parents don't necessarily forget details when they are under stress. They may be anxious or emotional, but they should still be able to provide a consistent and coherent account of what happened.
Correct Answer is D
Explanation
Choice A reason: This is not a good intervention because it disregards the parent's and the child's religious beliefs and values. It may also imply that the nurse knows better than the parent what is best for the child.
Choice B reason: This is not a necessary intervention because it does not address the immediate issue of the child's nutrition. It may also suggest that the nurse thinks the parent needs spiritual guidance or counseling.
Choice C reason: This is not a respectful intervention because it violates the parent's and the child's right to follow their dietary rules. It may also cause the parent and the child to feel guilty or conflicted.
Choice D reason: This is the best intervention because it honors the parent's and the child's preferences and practices. It also ensures that the child receives adequate and appropriate nutrition.
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