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 ["A","B"]
Explanation
Choice A reason: This response is correct because antibiotics are indicated for bacterial pneumonia caused by staphylococcus. Antibiotics help to fight the infection and prevent complications.
Choice B reason: This response is correct because cluster care means grouping nursing interventions together to minimize the disruption of the child's rest and sleep. Cluster care helps to conserve the child's energy and promote healing.
Choice C reason: This response is not correct because fluids are essential for hydration and thinning of secretions in pneumonia. Fluids help to prevent dehydration and facilitate expectoration of mucus.
Choice D reason: This response is not correct because antitussive agents are not recommended for pneumonia. Antitussive agents suppress the cough reflex, which is a natural mechanism to clear the airways of secretions. Antitussive agents may increase the risk of respiratory infection and atelectasis.
Correct Answer is D
Explanation
Choice A reason: The child's current vital signs are consistent with vital signs over the past 4 hours. This does not indicate that the child is in pain, as the vital signs may be within normal range or stable.
Choice B reason: The child becomes quiet when held and cuddled. This may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain.
Choice C reason: The child has just returned from the recovery room. This may indicate that the child is still under the influence of anesthesia or sedation, not that the child is in pain.
Choice D reason: The child is lying rigidly in bed and not moving. This is a sign of pain in children, as they may try to avoid movement or stimulation that could worsen their pain. The nurse should assess the child's pain level and administer pain medication as prescribed.
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