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
The nurse should advise the client to avoid taking St. John’s Wort with sertraline because it can increase the risk of a rare but serious condition called serotonin syndrome. Serotonin syndrome can cause symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhoea.
Choice B. Black cohosh is wrong because it is a herbal supplement that is used to treat menopausal symptoms and has no known interaction with sertraline.
Choice C. Coenzyme Q is wrong because it is a natural substance that is involved in energy production and has no known interaction with sertraline.
Choice D. Ginger root is wrong because it is a spice that is used to treat nausea and has no known interaction with sertraline.
Correct Answer is C
Explanation
Taking a high-ceiling diuretic predisposes this client to developing digoxin toxicity because it can cause hypokalemia (low blood potassium level), which increases the sensitivity of the heart to digoxin. Digoxin is a medicine that is used to treat heart failure or arrhythmias (abnormal heart rhythms) by increasing cardiac contractility and controlling the heart rate. Digoxin toxicity happens when there is too much digoxin in the body and it becomes harmful, causing symptoms such as nausea, vomiting, headache, confusion, vision disturbance, and irregular heartbeat.
Choice A is wrong because taking an HMG CoA reductase inhibitor (also called a statin) does not increase the risk of digoxin toxicity.
Statins are lipid-lowering medications used to prevent coronary heart disease by blocking an enzyme involved in cholesterol synthesis.
Statins do not affect the blood potassium level or the sensitivity of the heart to digoxin.
Choice B is wrong because having a 10-year history of COPD (chronic obstructive pulmonary disease) does not increase the risk of digoxin toxicity. COPD is a lung condition that causes breathing difficulties and chronic inflammation.
COPD does not affect the blood potassium level or the sensitivity of the heart to digoxin.
Choice D is wrong because having a prolapsed mitral valve does not increase the risk of digoxin toxicity.
A prolapsed mitral valve is a condition where the valve between the left atrium and left ventricle of the heart does not close properly, allowing some blood to leak back into the atrium.
A prolapsed mitral valve does not affect the blood potassium level or the sensitivity of the heart to digoxin.
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