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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the most appropriate action because it respects the youth's autonomy and maturity, and allows for timely and necessary intervention. Assent is the agreement of a minor to participate in a medical decision, and it is usually sufficient in emergency situations when parental consent is not available.

Choice B reason: This is not the most appropriate action because it may delay the surgery and put the youth at risk of further complications. Another relative may not have the legal authority to consent for the youth, and may not be reachable in time.

Choice C reason: This is not the most appropriate action because it does not address the underlying problem of the injury. Pain medications may provide temporary relief, but they may also mask the symptoms and interfere with the surgery.

Choice D reason: This is not the most appropriate action because it may jeopardize the youth's health and safety. Waiting for parents to obtain consent may result in irreversible damage or even death. The youth's best interest should be the priority in this case.

A. Administer Synagis® immediately and encourage fluids by mouth. B. Administer antiviral medication, limit fluids and give antitussives. C. Encourage fluids by mouth, IV antibiotics, and oxygen mist therapy. D. Provide oxygen mist therapy, administer IV fluids, and hand washing.

Correct Answer is D

Explanation

Choice A reason: This is not the correct answer because Synagis® is a monoclonal antibody that is given as a prophylaxis to prevent severe RSV infection in high-risk infants. It is not effective as a treatment for RSV bronchiolitis.

Choice B reason: This is not the correct answer because antiviral medication is not routinely recommended for RSV bronchiolitis, as it has not been shown to improve outcomes. Limiting fluids and giving antitussives may also be harmful, as they can cause dehydration and suppress the cough reflex.

Choice C reason: This is not the correct answer because IV antibiotics are not indicated for RSV bronchiolitis, which is a viral infection. Antibiotics may increase the risk of antibiotic resistance and adverse effects.

Choice D reason: This is the correct answer because oxygen mist therapy can help humidify the air and relieve the respiratory distress. IV fluids can prevent dehydration and maintain electrolyte balance. Hand washing can prevent the spread of RSV infection to other patients and staff.

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Which assessment indicates to a nurse that a school-age child is in need of pain medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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