Nokea
A 7-year-old child is experiencing pain after an appendectomy. Which data collection tool should the nurse use to assess the pain?
- A. Visual analog scale.
- B. Short Form McGill Questionnaire.
- C. FACES Pain Rating Scale.
- D. Numeric Pain Intensity Scale.
Correct Answer: C
Rationale: The FACES scale is age-appropriate for a 7-year-old to assess pain.
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A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse should:
- A. Explain that the medication should be discontinued during illness.
- B. Arrange for the pump to be refilled in the hospital.
- C. Reschedule the pump refill for the day of discharge.
- D. Instruct caregivers to call for a refill when the low-volume alarm sounds.
Correct Answer: B
Rationale: Arranging for the pump to be refilled in the hospital ensures continuous therapy, as interrupting baclofen can cause withdrawal symptoms.
When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include?
- A. Adhere to the same schedule and type and amount of insulin.
- B. Immediately call the physician for information about what to do.
- C. Adjust insulin based on more frequent testing of blood glucose levels.
- D. Take the child to the emergency department for immediate care.
Correct Answer: C
Rationale: Sick-day management requires frequent glucose monitoring and insulin adjustments to prevent ketoacidosis. Fixed insulin schedules, immediate physician calls, or ER visits are less appropriate without monitoring.
The parents of a preschooler ask the nurse how to handle their child's temper tantrums. Which of the following should the nurse include in the teaching plan? Select all that apply.
- A. Putting the child in 'time-out.'
- B. Telling the child to go to his bedroom.
- C. Ignoring the child.
- D. Putting the child to bed.
- E. Spanking the child.
- F. Trying to reason with the child.
Correct Answer: A,C
Rationale: Time-out and ignoring the tantrum are effective strategies to reduce attention-seeking behavior.
A child with a peanut allergy is prescribed an epinephrine auto-injector. The nurse should teach the parents to administer it in which situation?
- A. Mild itching after eating peanuts.
- B. Swelling of the lips and tongue.
- C. Upset stomach after exposure.
- D. Fatigue after a meal.
Correct Answer: B
Rationale: Lip and tongue swelling indicates anaphylaxis, requiring immediate epinephrine. Itching, upset stomach, or fatigue are less severe and managed differently.
A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following first?
- A. Administering an emetic.
- B. Performing a tracheostomy.
- C. Performing gastric lavage.
- D. Inserting an indwelling urinary (Foley) catheter.
Correct Answer: C
Rationale: Gastric lavage is the priority to remove the corrosive substance from the stomach, preventing further damage. Emetics are contraindicated for corrosives as they can worsen injury. Tracheostomy may be needed later for airway issues, and a urinary catheter is not relevant initially.