When assessing a child's pain, the best approach is for the nurse to:
Use self-parent report, behavioral, and physiological factors.
Ask the parents for a pain rating.
Look for behavioral clues for pain such as crying.
Use measures of heart rate and respiratory rate.
The Correct Answer is A
Choice A reason: This is the most comprehensive and accurate way of assessing a child's pain, as it takes into account the child's own perception, the parent's observation, and the objective signs of pain.
Choice B reason: This is not the best approach, as the parents may not be able to accurately rate the child's pain, especially if the child is too young or has communication difficulties.
Choice C reason: This is not the best approach, as behavioral clues may not always reflect the intensity or quality of pain, and may be influenced by other factors such as fear, anxiety, or coping strategies.
Choice D reason: This is not the best approach, as physiological measures may not always correlate with pain, and may be affected by other variables such as medication, stress, or illness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The child has a high fever is not a correct answer because fever is not a specific sign of croup. Fever can occur in many respiratory infections, such as bronchiolitis, pneumonia, or tonsillitis.
Choice B reason: Wheezing is heard audibly is not a correct answer because wheezing is not a characteristic feature of croup. Wheezing is more common in asthma or bronchiolitis, which affect the lower airways.
Choice C reason: It is bacterial in nature is not a correct answer because croup is usually caused by a virus, such as parainfluenza, adenovirus, or respiratory syncytial virus. Bacterial croup is rare and more severe, requiring hospitalization and antibiotics.
Choice D reason: It has a harsh, barking cough is the correct answer because it is the most distinctive symptom of croup. The cough is caused by the inflammation and narrowing of the larynx and trachea, which produce a sound similar to a seal's bark.
Correct Answer is D
Explanation
Choice A reason: The child's current vital signs are not a reliable indicator of pain, as they may vary depending on the child's condition, medication, and stress level. Vital signs alone are not sufficient to assess pain in children.
Choice B reason: The child becoming quiet when held and cuddled may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain. In fact, some children may become more vocal and restless when they are in pain.
Choice C reason: The child having just returned from the recovery room does not necessarily mean that the child is in pain. The child may have received pain medication during or after the surgery, or the child may have a different pain threshold. The nurse should not assume that the child is in pain based on the procedure alone.
Choice D reason: The child lying rigidly in bed and not moving is a sign of pain in children, as they may try to avoid movement that could aggravate their pain. The child may also exhibit facial expressions, such as grimacing, frowning, or clenching their teeth, that indicate pain. The nurse should assess the child's pain level and administer pain medication as ordered.
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