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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The most appropriate action for the nurse to take in this situation is:

d. Apply a warm, moist compress.

Here's why the other options are not recommended:

a. Initiate a new IV distal to the initial site:This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
b. Slow the IV solution rate:Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
c. Maintain the extremity below the level of the heart:This action would actually worsen the edema by promoting fluid accumulation at the site.

Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:

Stop the IV infusion.
Assess the extent of the infiltration or extravasation.
Document the findings.
Elevate the affected extremity.
Consult with a physician for further instructions and potential treatment.

A. Improved cognition. B. Cardiac arrhythmias absent. C. Decreased vomiting. D. Absent Chvostek’s sign.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client’s IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective?

Correct Answer is A

Explanation

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