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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Recommending the use of a wheelchair can help prevent stress on the lower extremities, which is important for an adolescent with muscular dystrophy. This condition can lead to muscle weakness and using a wheelchair can aid in mobility and independence.
Choice B reason: Avoiding influenza and pneumococcal vaccines is not recommended. Vaccinations are important for preventing infections, especially in individuals with compromised health conditions like muscular dystrophy.
Choice C reason: Initiating a referral for chest physiotherapy every 4 hours can be beneficial for an adolescent with muscular dystrophy. This therapy can help clear mucus from the lungs and improve respiratory function, which is often compromised in this condition.
Choice D reason: Encouraging the adolescent to perform incentive spirometry is important to maintain lung capacity. Muscular dystrophy can affect the muscles used for breathing, and incentive spirometry can help strengthen these muscles and improve respiratory health.
Correct Answer is D
Explanation
Choice A reason:
This option addresses electrical safety, which is important for preventing shocks and strangulation hazards in toddlers. However, it does not directly prevent burn injuries from hot water, which is the focus of the question. While hiding wires reduces overall household risks, it does not mitigate scalding hazards. Therefore, this choice is not the correct answer in the context of hot water burn prevention.
Choice B reason:
Turning pot handles toward the back of the stove is a well-known safety measure to prevent toddlers from pulling down hot pots and pans. This reduces the risk of scalds and burns in the kitchen environment. However, the question specifically emphasizes hot water burns, which are more commonly caused by tap water and bathing accidents. Thus, while helpful, this measure does not directly address the hazard highlighted in the scenario.
Choice C reason:
Encouraging outdoor play outside peak sun hours is a measure aimed at reducing sunburn and heat exposure. Sunburn is technically a type of burn, but it is not related to hot water scalds. The question focuses on preventing injuries from household hot water sources, making this option less relevant. While beneficial for overall child safety, it does not answer the specific teaching point.
Choice D reason:
Setting the water heater to 49°C (120°F) is the most effective intervention to prevent scald injuries from hot water in toddlers. Toddlers are at high risk of burns during bathing or when exposed to hot tap water. Lowering the water heater temperature reduces the severity of burns if accidental exposure occurs. This measure directly addresses the hazard in the question, making it the correct answer.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.