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
Explanation
Choice A reason: Avoiding raw fruits and vegetables is crucial for a child with neutropenia because these foods can harbor bacteria that may cause infection in a child with a weakened immune system. It is important to minimize the risk of infection by providing a diet that includes cooked or thoroughly washed fruits and vegetables.
Choice B reason: Administering vaccines prior to discharge may not be appropriate for a child with neutropenia, as live vaccines are contraindicated due to the risk of infection. Vaccination should be deferred until the child's immune system has recovered.
Choice C reason: Obtaining the child's rectal temperature once daily is not recommended for a child with neutropenia due to the risk of introducing bacteria into the body, which can lead to infection.
Choice D reason: Bathing the child every other day does not directly relate to the care of neutropenia. While personal hygiene is important, the frequency of bathing should be based on the child's needs and condition.
Correct Answer is D
Explanation
Choice A reason: Contact precautions are used for infections that spread by direct or indirect contact with the patient or the patient's environment. While important, they are not the primary precaution for pertussis.
Choice B reason: Airborne precautions are used for diseases that are transmitted through the air over long distances, such as tuberculosis. Pertussis does not typically require airborne precautions.
Choice C reason: Protective precautions are used to protect immunocompromised patients from being infected by others. This is not applicable for a child with pertussis, who is the source of infection.
Choice D reason: Droplet precautions are used for diseases that are transmitted through large droplets expelled during coughing, sneezing, or talking. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets, making droplet precautions the appropriate choice.
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