Which assessment indicates to a nurse that a school-age child is in need of pain medication?
The child's current vital signs are consistent with vital signs over the past 4 hours.
The child becomes quiet when held and cuddled.
The child has just returned from the recovery room.
The child is lying rigidly in bed and not moving.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because the girl's symptoms indicate that she may have epiglottitis, a life-threatening condition that causes swelling of the epiglottis and obstructs the airway. The nurse should be prepared for a possible intubation or tracheostomy.
Choice B reason: This is not the correct answer because making the girl lie down and rest quietly may worsen her respiratory distress and anxiety. The girl should be allowed to sit in a position of comfort and ease of breathing.
Choice C reason: This is not the correct answer because a thorough neurological assessment is not the priority in this situation. The nurse should focus on the girl's airway, breathing, and circulation.
Choice D reason: This is not the correct answer because auscultating the lungs and preparing for administering oxygen may not be sufficient to manage the girl's airway obstruction. The nurse should also have emergency equipment ready and call for assistance.
Correct Answer is D
Explanation
Choice A reason: This is not a good intervention because it disregards the parent's and the child's religious beliefs and values. It may also imply that the nurse knows better than the parent what is best for the child.
Choice B reason: This is not a necessary intervention because it does not address the immediate issue of the child's nutrition. It may also suggest that the nurse thinks the parent needs spiritual guidance or counseling.
Choice C reason: This is not a respectful intervention because it violates the parent's and the child's right to follow their dietary rules. It may also cause the parent and the child to feel guilty or conflicted.
Choice D reason: This is the best intervention because it honors the parent's and the child's preferences and practices. It also ensures that the child receives adequate and appropriate nutrition.
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