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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Rotavirus The nurse does not need to administer the Rotavirus vaccine in this scenario. Rotavirus immunization is typically given to infants between 2 and 6 months of age to protect against severe diarrhea caused by the virus. Since the child in question is 4 years old and up to date on current immunizations, this vaccine is not necessary.
Choice B reason:
Hepatitis B (Hep B) Similarly, the Hepatitis B vaccine is usually given shortly after birth and completed in a series of doses over the first year of life. Since the 4-year-old child is up to date on immunizations, the Hep B vaccine would have already been administered as part of the routine childhood vaccination schedule.
Choice C reason:
Varicella The Varicella vaccine, also known as the chickenpox vaccine, is typically given between 12 and 15 months of age and then again at 4 to 6 years old. Since the child is 4 years old and up to date on immunizations, it is now time for them to receive the second dose of the Varicella vaccine, making Choice C the correct answer.
Choice D reason:
Haemophilus influenza (Hib) The Haemophilus influenza (Hib) vaccine is usually given to infants starting at 2 months of age and is administered in multiple doses. By 4 years old, the child would have completed the primary series of the Hib vaccine. Therefore, there is no need to administer this vaccine again.
Correct Answer is B
Explanation
Choice A reason:
The nurse should not initiate contact precautions for a child with suspected epiglottitis. Epiglottitis is primarily caused by Haemophilus influenzae type B, and it spreads through respiratory droplets. Contact precautions are not necessary as the transmission occurs through droplets, and standard precautions should be sufficient.
Choice B reason:
The nurse should monitor pulse oximetry. Epiglottitis is a condition where the epiglottis becomes inflamed and swollen, potentially blocking the airway. Monitoring the child's pulse oximetry helps assess their oxygen saturation levels, which is crucial in determining if there is adequate oxygenation. If the oxygen saturation drops significantly, immediate intervention might be needed to maintain the child's airway and prevent hypoxia.
Choice C reason:
Obtaining a throat culture is not an appropriate intervention for suspected epiglottitis. In cases of suspected epiglottitis, the priority is to ensure the child's airway is maintained and that they receive appropriate medical attention promptly. Throat culture collection involves swabbing the throat to identify the infectious agent and is not a priority in this urgent situation.
Choice D reason:
Administering epinephrine IM is not indicated for suspected epiglottitis. Epinephrine is typically used to treat severe allergic reactions (anaphylaxis) and not for managing epiglottitis. The primary focus in epiglottitis is securing the airway and providing appropriate medical treatment, which might include antibiotics and respiratory support.
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