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A nurse is collecting data from a 5-month-old infant who is postoperative following umbilical hernia repair. Which of the following measures should the nurse use to evaluate the infant's pain level?
- A. FLACC pain rating scale
- B. COMFORT pain rating scale
- C. FACES pain rating scale
- D. CRIES pain rating scale
Correct Answer: A
Rationale: FLACC is ideal for non-verbal infants post-surgery. COMFORT suits ICU settings, FACES is for older children, and CRIES is for neonates up to 6 months.
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A nurse is reinforcing teaching with the parent of a school-age child who is undergoing testing for acute lymphoid leukemia (ALL). The nurse should inform the parent that the child will undergo which of the following tests to confirm the diagnosis?
- A. Spinal fluid analysis
- B. Complete blood count
- C. Bone marrow biopsy
- D. Bleeding time
Correct Answer: C
Rationale: Bone marrow biopsy is the definitive test to confirm ALL by examining marrow for abnormal cells. Spinal fluid analysis and CBC may support diagnosis but are not confirmatory. Bleeding time assesses platelet function, not leukemia.
A nurse is reinforcing teaching with the parents of a preschooler who has recently started to stutter. Which of the following instructions should the nurse include?
- A. Critique your child's speech.
- B. Look away from your child when they start to stutter.
- C. Avoid completing your child's sentences.
- D. Tell your child to take a deep breath when they are stuttering.
Correct Answer: C
Rationale: Avoiding sentence completion reduces pressure and supports fluency. Critiquing, looking away, or suggesting deep breaths may increase anxiety and worsen stuttering.
A nurse is reinforcing teaching with the parent of a child who has diabetes mellitus. The parent asks the nurse how to minimize the child's pain when monitoring blood glucose levels. Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child should use their index finger to obtain blood samples.
- B. My child should hold their finger under warm water before obtaining a sample.
- C. My child should puncture the center of their finger pad when obtaining a sample.
- D. My child should hold their finger against a table when obtaining a sample.
Correct Answer: B
Rationale: Warm water increases blood flow, reducing pain during glucose monitoring. Index finger use, central punctures, or table pressure do not specifically minimize discomfort.
A nurse is making a home visit to a 5-year-old child who has cerebral palsy and uses a wheelchair. Which of the following observations made by the nurse indicates that the family needs support and resources to cope with the child's condition?
- A. A grandparent is assisting the child in performing ADLs.
- B. The child is playing a game with their siblings.
- C. The parent is withdrawn and rarely interacts with the child.
- D. The step-parent is helping the child prepare to transition into school.
Correct Answer: C
Rationale: A withdrawn parent suggests emotional distress or difficulty coping, indicating a need for support. Grandparent assistance, sibling play, and step-parent involvement reflect positive family engagement.
A nurse is reinforcing teaching with the parent of a child who has a bacterial upper respiratory infection. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will force my child to drink fluids when they have a fever.
- B. I will use a dehumidifier in my child's room.
- C. I will keep my child's towels separate from those of the rest of the family.
- D. I will make sure my child eats three meals a day, even though their appetite is not good right now.
Correct Answer: C
Rationale: Separating towels prevents infection spread. Forcing fluids, using a dehumidifier, or insisting on three meals are not specific or recommended for bacterial infections.