A nurse is caring for a 4-year-old child following an orthopedic 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
A. For assessing pain in a 4-year-old child following an orthopedic procedure, the nurse should use the FACES pain scale.
The FACES pain scale uses a series of faces with varying expressions, from smiling to crying, to help children express their level of pain. Children are asked to point to the face that best matches how they feel. This scale is particularly useful for young children who may not have the verbal skills to describe their pain accurately using words or numbers.
B. Word-graphic
Explanation: The word-graphic pain scale typically uses a combination of words and drawings to assess pain, making it more suitable for children who are slightly older and can understand simple words and concepts.
C. Numeric
Explanation: The numeric pain scale involves asking the child to rate their pain on a scale from 0 to 10. This scale is more appropriate for older children who can understand and assign numerical values to their pain intensity.
D. CRIES
Explanation: The CRIES pain scale is often used for assessing pain in newborns and infants up to 6 months old. It focuses on crying, oxygen saturation, vital signs, and facial expressions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pallor:
Incorrect Explanation: While pallor (pale skin) can be a sign of an allergic reaction, it is not a specific indication of an allergic reaction to penicillin.
Explanation: Pallor can occur for various reasons, including shock or vasovagal responses, and it is not unique to allergic reactions.
B. Dyspepsia:
Incorrect Explanation: Dyspepsia (indigestion or upset stomach) is not a typical sign of an allergic reaction.
Explanation: Allergic reactions are more commonly associated with skin, respiratory, and cardiovascular symptoms, rather than gastrointestinal symptoms like dyspepsia.
C. Bradycardia:
Incorrect Explanation: Bradycardia (slow heart rate) is not a typical indicator of an allergic reaction.
Explanation: Allergic reactions generally do not directly cause bradycardia. Rapid heart rate (tachycardia) can be a symptom of an allergic reaction in some cases.
D. Urticaria:
Correct Answer: Urticaria (hives) is a common and characteristic sign of an allergic reaction, including to penicillin.
Explanation: Urticaria presents as raised, itchy, and often red welts on the skin. It is a classic manifestation of an allergic response and can occur rapidly after exposure to an allergen, including medications like penicillin.
Correct Answer is D
Explanation
A. Decrease in protein:
This choice is incorrect. Albumin is a protein found in the blood, and when a client is receiving an infusion of albumin, it is likely to increase, not decrease, the overall protein level in the bloodstream. Albumin infusions are often given to help increase plasma oncotic pressure and improve fluid retention in conditions like shock.
B. Oxygen saturation 96%:
This choice is incorrect. Oxygen saturation of 96% is within the normal range and reflects adequate oxygenation. It doesn't directly relate to the administration of albumin in shock.
C. PaCO2 30 mm Hg:
This choice is incorrect. The partial pressure of carbon dioxide (PaCO2) of 30 mm Hg reflects a respiratory value and doesn't directly relate to the administration of albumin or the management of shock. It's important for assessing acid-base balance, but it's not a specific finding related to the albumin infusion.
D. Increase in BP:
This is the correct choice. Albumin is a colloid solution that helps increase the oncotic pressure within blood vessels, which can contribute to an increase in blood volume. When blood volume increases, it can lead to an increase in blood pressure, which is a desired effect in the management of shock. Increasing blood pressure helps improve perfusion to vital organs and tissues, which is essential in shock situations.
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