A nurse is planning to collect data on the pain level of a 3-year-old child. Which of the following pain rating scales should the nurse plan to use?
Visual analog scale.
FACES.
Word-graphic.
Numeric.
The Correct Answer is B
Choice A reason:
The Visual Analog Scale (VAS) is a pain rating scale that involves a straight line with one end representing "no pain” and the other end representing "worst pain imaginable.” The individual marks a point on the line to indicate their pain level. This scale may not be suitable for a 3-year-old child as it requires a certain level of cognitive and numerical understanding to make a meaningful assessment, which a young child may not possess.
Choice B reason:
The FACES pain rating scale is a visual tool that uses a series of facial expressions ranging from smiling to crying to help individuals, especially children, express their pain level. A 3-year-old child can easily point to the facial expression that best matches their pain experience, making it a suitable choice for this age group.
Choice C reason:
The Word-Graphic Scale is a pain rating scale that combines verbal descriptors with a visual representation of the pain intensity. It may include words like "no pain,” "mild pain,” "moderate pain,” and "severe pain” along with corresponding symbols. While it can be used with children, a 3-year-old might have difficulty grasping the abstract nature of the scale and correlating words with pain levels.
Choice D reason:
The Numeric Rating Scale (NRS) requires the individual to rate their pain level on a scale from 0 to 10, with 0 being "no pain” and 10 being "worst pain.” Similar to the Visual Analog Scale, this scale might not be suitable for a 3-year-old child who may not fully understand abstract numerical concepts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I should start trying to breastfeed within an hour of having my baby.” Choice A reason:
The client's statement indicates an understanding of the teaching because initiating breastfeeding within the first hour after birth is crucial for successful breastfeeding. This early initiation allows the baby to receive colostrum, which is rich in nutrients and antibodies, supporting the baby's immune system and providing essential nutrition during the initial stages of life. Additionally, early breastfeeding helps establish a strong bond between the mother and the baby while promoting the baby's suckling reflex.
Choice B reason:
The statement in Choice B is incorrect. Formula feeding between breastfeedings is not recommended in the early stages of breastfeeding, especially if the baby loses 5 percent of their birth weight. Newborns often lose some weight initially, which is normal, and it can be regained through effective breastfeeding. Supplementing with formula may interfere with establishing a good milk supply and the baby's ability to latch properly.
Choice C reason:
This statement in Choice C is incorrect. During breastfeeding sessions, it's essential for the baby to nurse on one breast fully before switching to the other breast. Allowing the baby to nurse for at least 10-15 minutes on each breast ensures they receive the hindmilk, which is higher in fat and essential for the baby's growth and development.
Choice D reason:
The statement in Choice D is incorrect. Offering a pacifier right after breastfeeding might interfere with the baby's feeding cues and lead to decreased breastfeeding frequency.
Newborns may suck for non-nutritive reasons, and offering a pacifier too soon can hinder proper breastfeeding establishment, as they may satisfy their sucking needs with the pacifier rather than nursing at the breast.
Correct Answer is C
Explanation
"I will reinforce the patch edges with clear tape if they don't lie flat.".
Choice A reason:
Placing a heat pack on the patch to improve adhesion is not recommended. Heat can potentially increase the absorption of the medication and lead to adverse effects. Applying additional heat to the patch can be dangerous and may cause an overdose or other complications.
Choice B reason:
Placing the patch on the back side of the child's arm is not the correct application site for a methylphenidate transdermal patch. The appropriate site for application is typically the hip or the top of the buttocks. The back of the arm may not provide proper absorption and can result in suboptimal medication delivery.
Choice C reason:
This statement indicates an understanding of the teaching. Reinforcing the patch edges with clear tape if they don't lie flat is a recommended step to ensure proper adhesion of the patch. If the edges of the patch lift or don't stick properly, using clear tape can help keep the patch securely in place, ensuring continuous and consistent drug delivery.
Choice D reason:
Leaving the patch in place for no more than 9 hours is incorrect. The duration of wear for a methylphenidate transdermal patch varies depending on the specific brand and formulation. Typically, these patches are designed for 9 to 12 hours of wear, and leaving them on for a shorter duration may result in inadequate symptom control.
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