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The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?
- A. Poker chip tool
- B. Oucher Scale
- C. Faces Pain Rating Scale
- D. FLACC Behavioral Pain Assessment Scale
Correct Answer: D
Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.
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What self-report pain rating scales can be used in children as young as 3 years of age?
- A. Poker Chip Tool
- B. Visual Analog Scale
- C. FACES Pain Rating Scale
- D. Word-Graphic Rating Scale
Correct Answer: C
Rationale: The FACES Pain Rating Scale is suitable for children as young as 3 years of age. It uses facial expressions to depict different levels of pain, making it easy for young children to understand and use. The Poker Chip Tool is validated for children aged 4 and older who have a certain level of cognitive ability. The Visual Analog Scale is more appropriate for children aged 7 and above. The Word-Graphic Rating Scale, which uses descriptive words, is recommended for children in the age range of 4 to 17 years.
A teenager is accompanied by his mother to the annual physical examination. The nurse is aware of privacy issues related to the teenager. While the mother is in the room, which topic should the nurse avoid?
- A. School performance
- B. Seatbelt use
- C. Cigarette smoking
- D. School friends
Correct Answer: C
Rationale: The correct answer is C: Cigarette smoking. Discussing sensitive topics like cigarette smoking in the presence of a parent may inhibit the teenager's willingness to be open and honest. It's important to provide an opportunity for the teenager to speak privately with the healthcare provider. Choices A, B, and D are more general topics that can be discussed openly in front of the parent without compromising the teenager's privacy or comfort.
What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
- A. Rinne test
- B. Weber test
- C. Pure tone audiometry
- D. Eliciting the startle reflex
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?
- A. Use the small cuff
- B. Use the large cuff
- C. Use either cuff using the palpation method
- D. Wait to take the blood pressure until a proper cuff can be located
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?
- A. This cannot be prevented
- B. Infants do not feel pain as adults do
- C. This is not a good reason for refusing
- D. A topical anesthetic can be applied
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.