A nurse is caring for a 9-year-old client who is immediately postoperative. The client is nonverbal and has both cognitive and developmental delays. Which of the following pain scales should the nurse use to evaluate the client's pain?

Choice A reason: The correct answer is choice A. The nurse should expect the presence of the Moro reflex in a 6-month-old infant. The Moro reflex is a normal primitive reflex seen in infants up to about 6 months of age. When the infant experiences a sudden loss of support or a loud noise, they react by extending their arms and legs and then pulling them back in, as if trying to grasp onto something. This reflex is an important indicator of the baby's neurological development.

Choice B reason:

The birth weight doubling by 6 months of age is a typical growth milestone for infants. However, this statement is not correct in the context of the question, as it is not something the nurse should "expect” during a well-child visit. Instead, it is a general developmental milestone that healthcare providers monitor over time.

Choice C reason:

The correct answer is choice C. The nurse should expect the posterior fontanel to be closed in a 6-month-old infant. Fontanels are soft spots on a baby's skull that allow for brain growth during early development. The posterior fontanel, located at the back of the head, is typically closed by 6 months of age.

Choice D reason:

The correct answer is choice D. At 6 months of age, many infants can sit unsupported. However, not all infants achieve this milestone at the exact same age. Some may achieve it a bit earlier, while others might take a little more time. It is essential for the nurse to assess the infant's developmental progress and provide appropriate guidance to the parents.

Choice E:

The correct answer is choice E. By 6 months of age, some infants may be able to move from their back to their front. This is usually accomplished through rolling over. However, like other developmental milestones, the age at which infants achieve this can vary. Therefore, while the nurse may expect this ability in some infants, it is not something that all 6-month- old infants will have mastered at the time of the well-child visit.

Adolescents tend to believe their own actions might have caused their terminal illness. Choice A reason:

This statement reflects a common developmental focus for adolescents, who are often navigating issues related to identity and self-image. While they are aware of their illness, many may prioritize concerns about how they look and how they are perceived by others. This can be a significant aspect of their experience during a terminal illness.

Choice B reason:

Many adolescents imagine death as a type of monster. Although this statement acknowledges a common perception of death among some adolescents, it is not the best choice for reinforcing teaching about the perception of death in the context of a terminal illness. The focus should be on more concrete and realistic aspects of death and its implications.

Choice C reason:

This statement does reflect a valid concern but may not be as prevalent as the concern with appearance in this age group. Many adolescents, especially in a terminal situation, may focus on more immediate concerns, such as how they are perceived.

Choice D reason:

Many adolescents don't understand that death is permanent. While this statement may be true for some adolescents who are still developing a full comprehension of death, it is not the most suitable choice for this scenario. In the context of a terminal illness, it is essential to acknowledge that the adolescent likely has a clear understanding of the finality of death.