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?

Choice A reason:

One cup of oatmeal - Oatmeal is a nutritious food, but it does not contain as high a protein content as some other options. While it offers some protein, it is not the best choice for a high-protein diet during pregnancy. Oatmeal is primarily known for its fiber content and complex carbohydrates, which provide sustained energy.

Choice B reason:
One cup of tofu - Tofu is an excellent source of protein and is a suitable choice for a high- protein diet during pregnancy. Tofu is made from soybeans and is rich in plant-based proteins, making it an ideal option for individuals following a vegetarian or vegan diet as well. Additionally, tofu contains essential amino acids, iron, calcium, and other nutrients beneficial for both the mother and the developing fetus.

Choice C reason:

One cup of brown rice - While brown rice is a healthy whole grain and provides some protein, it does not have as high a protein content as tofu. Brown rice is a good source of complex carbohydrates, fiber, vitamins, and minerals, but it may not meet the high protein requirements of a pregnant woman's diet.

Choice D reason:

One cup of kale - Kale is a nutritious leafy green vegetable, but it does not offer a significant amount of protein compared to tofu. It is rich in vitamins, minerals, and antioxidants, making it a valuable addition to a balanced diet. However, for a high-protein diet during pregnancy, other options like tofu are more suitable.

The nurse should maintain continuous observation of the adolescent.

Choice A reason:

The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.

Choice B reason:

Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.

Choice C reason:

Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.

Choice D reason:

Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.