A nurse is caring for a 4-year-old child following an orthopaedic procedure. When assessing the child for pain, which of the following pain scales should the nurse use?
FACES.
Word-graphic.
Numeric.
CRIES.
The Correct Answer is A
The FACES pain scale is a self-report tool that uses six facial expressions to indicate different levels of pain. It is suitable for children aged 3 to 13 years who can match their pain to a face. The nurse should use this scale to assess the pain of a 4-year-old child following an orthopaedic procedure.
Choice B. Word-graphic is wrong because it is a pain scale that uses words and pictures to describe pain intensity.
It is suitable for children aged 8 to 17 years who can read and understand words.
Choice C. Numeric is wrong because it is a pain scale that uses numbers from 0 to 10 to rate pain intensity. It is suitable for children aged 5 years and older who can understand numbers and concepts of more or less.
Choice D. CRIES is wrong because it is a pain scale that uses five behavioural indicators (crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness) to measure pain in neonates.
It is suitable for infants aged 0 to 6 months who cannot communicate verbally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hyponatremia is a condition where the sodium level in the blood is too low, which can cause confusion, lethargy, seizures, and coma. A hypertonic solution is a fluid that has a higher concentration of solutes than the blood, which can help raise the sodium level and reduce the brain swelling caused by hyponatremia. Therefore, improved cognition indicates that the treatment is effective.
Choice B. Cardiac arrhythmias absent.
Cardiac arrhythmias are not a common symptom of hyponatremia unless it is severe or rapid in onset.
Therefore, their absence does not necessarily indicate that the treatment is effective.
Choice C. Decreased vomiting.
Vomiting can be a cause or a consequence of hyponatremia, depending on the underlying condition.
Decreased vomiting may indicate that the patient is less nauseated, but it does not reflect the sodium level or the brain status.
Choice D. Absent Chvostek’s sign.
Chvostek’s sign is a facial twitching that occurs when tapping on the cheek, which indicates hypocalcemia (low calcium level).
It is not related to hyponatremia or hypertonic solution.
Normal ranges for sodium are 135 to 145 mEq/L and for calcium are 8.5 to 10.5 mg/dL.
Correct Answer is C
Explanation
This is the priority for the nurse to report to the provider because cefuroxime is a cephalosporin antibiotic that can cause serious or life-threatening allergic reactions in people who are allergic to penicillin. The nurse should not administer cefuroxime to this client until the provider is notified and an alternative antibiotic is prescribed.
Choice A is wrong because the client has a BUN level of 18 mg/dL, which is within the normal range of 7 to 20 mg/dL.
This does not indicate any renal impairment or adverse reaction to cefuroxime.
Choice B is wrong because the client reports a history of nausea with cefuroxime, which is a common side effect of this drug.
The nurse should instruct the client to take cefuroxime with food to reduce nausea, but this is not a priority to report to the provider.
Choice D is wrong because the client takes aspirin daily, which does not interact with cefuroxime.
The nurse should monitor the client for any signs of bleeding or bruising while taking aspirin, but this is not a priority to report to the provider.
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