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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hypothermia is not a common finding associated with inhalation of gasoline. It typically occurs due to exposure to cold temperatures and is not related to chemical inhalation.
Choice B reason: Hyperactive reflexes are not typically associated with gasoline inhalation. They can be a sign of neurological disorders or a response to certain medications, but not commonly from inhalants.
Choice C reason: Mydriasis, which is the dilation of the pupils, can occur with inhalation of gasoline due to its effect on the nervous system. It is a sign that the nurse should be aware of during the assessment.
Choice D reason: Pinpoint pupils are more commonly associated with opioid overdose and not with inhalation of gasoline. The nurse should expect to see dilated pupils rather than constricted ones.
Correct Answer is A
Explanation
Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.
Choice B reason: A BUN level of 6 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.
Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.
Choice D reason: A BUN level of 12 mg/dL is slightly elevated but may not be immediately concerning. It should be evaluated in conjunction with other laboratory values and clinical findings.
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