A nurse is caring for a school-age child who is experiencing pain. Which of the following assessment techniques will provide the nurse with the most accurate information regarding the child's pain?

Assess the child's pulse and respirations.

Observe the child's facial expressions.

Ask the child to use a FACES rating scale.

Monitor the child's involuntary movements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing the child's pulse and respirations can indicate pain through physiological changes, but these signs can be influenced by other factors and may not provide an accurate measure of pain intensity.

Choice B reason: Observing the child's facial expressions can give some indication of pain, but it is subjective and may not accurately reflect the child's pain experience, especially if the child is trying to hide their discomfort.

Choice C reason: Asking the child to use a FACES rating scale allows the child to actively participate in communicating their pain level. This method is age-appropriate and provides a visual way for children to express the intensity of their pain, making it a reliable assessment technique.

Choice D reason: Monitoring the child's involuntary movements can provide clues about pain, but like facial expressions, they are subjective and may not accurately quantify the child's pain level.

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Correct Answer is C

Explanation

Choice A reason: Avoiding the removal of the cream prior to the procedure is important, but it does not specify when or how the cream should be applied, which is crucial for its effectiveness.

Choice B reason: Rubbing the cream into the skin is not recommended as it should be applied as a thick layer and covered with an occlusive dressing to ensure proper absorption and numbing effect.

Choice C reason: Applying the cream 1 hour before the procedure allows enough time for the lidocaine and prilocaine to take effect, providing adequate local anesthesia for the insertion of the IV catheter.

Choice D reason: Washing the site with alcohol prior to applying the cream is necessary to clean the area, but it is not the action that addresses the primary goal of numbing the site for the procedure.

A. Loosen tight clothing around the child's neck. B. Firmly hold the child's arms to one side. C. Place a pillow under the child's head. D. Insert a tongue blade into the child's mouth. E. Clear the area of hard objects.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.

Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.

Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.

Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.

Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.

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A nurse is caring for a school-age child who is experiencing pain. Which of the following assessment techniques will provide the nurse with the most accurate information regarding the child's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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