Chapter 15 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 15

Question 1

Type: MCMA

The nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic and denies pain. Which nursing actions are most appropriate in this situation?

Standard Text: Select all that apply.

1. Use the FLACC scale to determine the childs pain level.

2. Tell the child to ring the call bell if the leg starts hurting.

3. Administer pain medication now and continue on a regular basis.

4. Ask the childs parents to notify the nurse if the child complains of pain.

5. Use the NIPS scale to determine the childs pain level.

Correct Answer: 1,3,4

Rationale 1: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.

Rationale 2: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.

Rationale 3: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.

Rationale 4: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.

Rationale 5: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.

Global Rationale: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 15.2 Analyze the behaviors of an infant or a child to assess for pain.

Question 2

Type: MCSA

During the nurses initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which action by the nurse is most appropriate?

1. Administer prescribed analgesic.

2. Ask the childs parents if they think the child is hurting.

3. Reassess the child in 15 minutes to see if the pain rating has changed.

4. Do nothing, since the child appears to be resting.

Correct Answer: 1

Rationale 1: School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.

Rationale 2: School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.

Rationale 3: School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.

Rationale 4: School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.

Global Rationale: School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 15.3 Assess the developmental abilities of children to perform a self-assessment of pain intensity.

Question 3

Type: MCSA

A school-age client has been receiving morphine every two hours for postoperative pain as ordered. The medication relieves the pain for approximately 90 minutes, and then the pain returns. Which action by the nurse is the most appropriate?

1. Tell the child that pain medication cannot be administered more frequently than every two hours.

2. Reposition the child and quietly leave the room.

3. Inform the parents that the child is dependent on the medication.

4. Call the healthcare provider to see if the childs orders for pain medication can be changed.

Correct Answer: 4

Rationale 1: The nurse has the responsibility of relieving the childs pain. The child has been receiving the prescribed medication on a regular basis. The healthcare provider should be called to see if the childs orders can be changed. This child might do well with patient-controlled analgesia (PCA). Oral medications such as acetaminophen and NSAIDs can be given with morphine to provide optimum pain relief.

Rationale 2: The nurse has the responsibility of relieving the childs pain. The child has been receiving the prescribed medication on a regular basis. The healthcare provider should be called to see if the childs orders can be changed. This child might do well with patient-controlled analgesia (PCA). Oral medications such as acetaminophen and NSAIDs can be given with morphine to provide optimum pain relief.

Rationale 3: The nurse has the responsibility of relieving the childs pain. The child has been receiving the prescribed medication on a regular basis. The healthcare provider should be called to see if the childs orders can be changed. This child might do well with patient-controlled analgesia (PCA). Oral medications such as acetaminophen and NSAIDs can be given with morphine to provide optimum pain relief.

Rationale 4: The nurse has the responsibility of relieving the childs pain. The child has been receiving the prescribed medication on a regular basis. The healthcare provider should be called to see if the childs orders can be changed. This child might do well with patient-controlled analgesia (PCA). Oral medications such as acetaminophen and NSAIDs can be given with morphine to provide optimum pain relief.

Global Rationale: The nurse has the responsibility of relieving the childs pain. The child has been receiving the prescribed medication on a regular basis. The healthcare provider should be called to see if the childs orders can be changed. This child might do well with patient-controlled analgesia (PCA). Oral medications such as acetaminophen and NSAIDs can be given with morphine to provide optimum pain relief.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 15.4 Plan the nursing care for a child receiving an opioid analgesic.

Question 4

Type: MCSA

The nurse is working in a pediatric surgical unit. In discussing patient-controlled analgesia (PCA) in a preoperative parental meeting, which client would be a candidate for PCA?

1. Developmentally delayed 16-year-old, postoperative bone surgery

2. 5-year-old, postoperative tonsillectomy

3. 10-year-old who has a fractured femur and concussion from a bike accident

4. 12-year-old, postoperative spinal fusion for scoliosis

Correct Answer: 4

Rationale 1: Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.

Rationale 2: Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.

Rationale 3: Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.

Rationale 4: Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.

Global Rationale: Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 15.7 Distinguish between the clinical therapies used for acute and chronic pain.

Question 5

Type: MCSA

A toddler is hospitalized with a fractured femur. In addition to pain medication, which will best provide pain relief for this child?

1. Parents presence at the bedside

2. Age-appropriate toys

3. Deep-breathing exercises

4. Videos for the child to watch

Correct Answer: 1

Rationale 1: Parents presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety.

Rationale 2: Parents presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety.

Rationale 3: Parents presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety.

Rationale 4: Parents presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety.

Global Rationale: Parents presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 15.7 Distinguish between the clinical therapies used for acute and chronic pain.

Question 6

Type: MCSA

The nurse is caring for a toddler client in the postoperative period. Which pain assessment tool is most appropriate for this client?

1. FLACC Behavioral Pain Assessment Scale

2. FACES pain scale

3. Oucher scale

4. Poker-chip tool

Correct Answer: 1

Rationale 1: The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The FACES Scale, Oucher scale, and poker-chip tool are all self-report scales.

Rationale 2: The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The FACES Scale, Oucher scale, and poker-chip tool are all self-report scales.

Rationale 3: The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The FACES Scale, Oucher scale, and poker-chip tool are all self-report scales.

Rationale 4: The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The FACES Scale, Oucher scale, and poker-chip tool are all self-report scales.

Global Rationale: The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The FACES Scale, Oucher scale, and poker-chip tool are all self-report scales.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 15.2 Analyze the behaviors of an infant or a child to assess for pain.

Question 7

Type: MCSA

A hospitalized toddler-age client needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate?

1. Ineffective Individual Coping Related to an Invasive Procedure

2. Anxiety Related to Anticipated Painful Procedure

3. Fear Related to the Unfamiliar Environment

4. Knowledge Deficit of the Procedure

Correct Answer: 2

Rationale 1: At this age, the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for a child of this age.

Rationale 2: At this age, the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for a child of this age.

Rationale 3: At this age, the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for a child of this age.

Rationale 4: At this age, the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for a child of this age.

Global Rationale: At this age,the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for a child of this age.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 15.1 Summarize the physiologic and behavioral consequences of pain in infants and children.

Question 8

Type: MCSA

A parent asks the nurse if there is anything that can be done to reduce the pain that his 3-year-old experiences each morning when blood is drawn for lab studies. Which intervention would the nurse implement based on the parents concern?

1. Intravenous sedation 15 minutes prior to the procedure

2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure

3. Use of guided imagery during the procedure

4. Use of muscle-relaxation techniques

Correct Answer: 2

Rationale 1: Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

Rationale 2: Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

Rationale 3: Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

Rationale 4: Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

Global Rationale: Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 15.6 Plan nursing care for an infant or child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies.

Question 9

Type: MCSA

As an advocate for the child undergoing bone-marrow aspiration, which intervention would the nurse suggest to decrease the pain experienced due to the procedure?

1. General anesthesia

2. Conscious sedation

3. Intravenous narcotics ten minutes before the procedure

4. Oral pain medication for discomfort after the procedure

Correct Answer: 2

Rationale 1: For the child undergoing repeated procedures, it is important for the child to be sedated prior to and during the initial procedure. General anesthesia is not necessary for bone-marrow aspiration. Narcotics alone will not provide appropriate sedation to keep the child from remembering the procedure. While oral pain medication postprocedure is not inappropriate if discomfort exists, it is not the best answer. The child will have great anxiety and discomfort during the procedures and prior to future procedures.

Rationale 2: For the child undergoing repeated procedures, it is important for the child to be sedated prior to and during the initial procedure. General anesthesia is not necessary for bone-marrow aspiration. Narcotics alone will not provide appropriate sedation to keep the child from remembering the procedure. While oral pain medication postprocedure is not inappropriate if discomfort exists, it is not the best answer. The child will have great anxiety and discomfort during the procedures and prior to future procedures.

Rationale 3: For the child undergoing repeated procedures, it is important for the child to be sedated prior to and during the initial procedure. General anesthesia is not necessary for bone-marrow aspiration. Narcotics alone will not provide appropriate sedation to keep the child from remembering the procedure. While oral pain medication postprocedure is not inappropriate if discomfort exists, it is not the best answer. The child will have great anxiety and discomfort during the procedures and prior to future procedures.

Rationale 4: For the child undergoing repeated procedures, it is important for the child to be sedated prior to and during the initial procedure. General anesthesia is not necessary for bone-marrow aspiration. Narcotics alone will not provide appropriate sedation to keep the child from remembering the procedure. While oral pain medication postprocedure is not inappropriate if discomfort exists, it is not the best answer. The child will have great anxiety and discomfort during the procedures and prior to future procedures.

Global Rationale: For the child undergoing repeated procedures, it is important for the child to be sedated prior to and during the initial procedure. General anesthesia is not necessary for bone-marrow aspiration. Narcotics alone will not provide appropriate sedation to keep the child from remembering the procedure. While oral pain medication postprocedure is not inappropriate if discomfort exists, it is not the best answer. The child will have great anxiety and discomfort during the procedures and prior to future procedures.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 15.8 Develop a nursing care plan for assessing and monitoring the child having sedation and analgesia for a medical procedure.

Question 10

Type: MCSA

A school-age client is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching?

1. I can expect my child to have some pain for the next few days.

2. I will plan to give my child pain medicine around the clock for the next day or so.

3. Since my child just had surgery today, I can expect the pain level to be higher tomorrow.

4. I will call the office tomorrow if the pain medicine is not relieving the pain.

Correct Answer: 3

Rationale 1: Increasing pain can be a sign of complication and should be reported to the physician; therefore, if the parent expects the pain to be higher the next day, the nurse should clarify expectations for pain control. The child is expected to have some pain for a few days after surgery and should receive pain medication on a scheduled basis. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.

Rationale 2: Increasing pain can be a sign of complication and should be reported to the physician; therefore, if the parent expects the pain to be higher the next day, the nurse should clarify expectations for pain control. The child is expected to have some pain for a few days after surgery and should receive pain medication on a scheduled basis. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.

Rationale 3: Increasing pain can be a sign of complication and should be reported to the physician; therefore, if the parent expects the pain to be higher the next day, the nurse should clarify expectations for pain control. The child is expected to have some pain for a few days after surgery and should receive pain medication on a scheduled basis. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.

Rationale 4: Increasing pain can be a sign of complication and should be reported to the physician; therefore, if the parent expects the pain to be higher the next day, the nurse should clarify expectations for pain control. The child is expected to have some pain for a few days after surgery and should receive pain medication on a scheduled basis. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.

Global Rationale: Increasing pain can be a sign of complication and should be reported to the physician; therefore, if the parent expects the pain to be higher the next day, the nurse should clarify expectations for pain control. The child is expected to have some pain for a few days after surgery and should receive pain medication on a scheduled basis. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 15.7 Distinguish between the clinical therapies used for acute and chronic pain.

Question 11

Type: MCSA

The nurse is caring for a child who has been sedated for a painful procedure. Which nursing activity is the priority for this child?

1. Allow parents to stay with the child.

2. Monitor pulse oximetry.

3. Assess the childs respiratory effort.

4. Place the child on a cardiac monitor.

Correct Answer: 3

Rationale 1: When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

Rationale 2: When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

Rationale 3: When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

Rationale 4: When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

Global Rationale: When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 15.8 Develop a nursing care plan for assessing and monitoring the child having sedation and analgesia for a medical procedure.

Question 12

Type: MCMA

A young school-age client is hospitalized with a fractured femur. Which assessment tools are appropriate for this client?

Standard Text: Select all that apply.

1. FACES pain scale

2. Oucher scale

3. Visual Analog Scale

4. CRIES Scale

5. Poker-chip tool

Correct Answer: 1,2,5

Rationale 1: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.

Rationale 2: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.

Rationale 3: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.

Rationale 4: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.

Rationale 5: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.

Global Rationale: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 15.3 Assess the developmental abilities of children to perform a self-assessment of pain intensity.

Question 13

Type: MCSA

The nurse is caring for a child who has a long leg cast. The child complains of increasing pain in the toes of the casted foot. Which initial action by the nurse is the most appropriate?

1. Call the healthcare provider to report increasing pain.

2. Administer pain medication.

3. Reposition the child in bed.

4. Check to see if the cast is too tight.

Correct Answer: 4

Rationale 1: While all of the actions are appropriate, the nurses initial action is to assess for external factors that might be causing pain.

Rationale 2: While all of the actions are appropriate, the nurses initial action is to assess for external factors that might be causing pain.

Rationale 3: While all of the actions are appropriate, the nurses initial action is to assess for external factors that might be causing pain.

Rationale 4: While all of the actions are appropriate, the nurses initial action is to assess for external factors that might be causing pain.

Global Rationale: While all of the actions are appropriate, the nurses initial action is to assess for external factors that might be causing pain.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 15.6 Plan nursing care for an infant or child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies.

Question 14

Type: MCSA

The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy is appropriate for the nurse to use decrease pain during this quick but painful procedure?

1. Swaddling

2. Sucrose pacifier

3. Massage

4. Holding the infant

Correct Answer: 2

Rationale 1: Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.

Rationale 2: Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.

Rationale 3: Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.

Rationale 4: Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.

Global Rationale: Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 15.5 Examine the role of nonpharmacologic (complementary) interventions in effective pain management.

Question 15

Type: MCSA

A preschool-age client is hospitalized following surgery for a ruptured appendix. During assessment of the child, the nurse notes that the child is sleeping. Vital signs are as follows: temperature 97.8 degrees F axillary, pulse 90, respirations 12, and blood pressure 100/60. Which conclusion by the nurse is appropriate based on the assessment findings?

1. The client is comfortable and the pain is controlled.

2. The client is in shock secondary to blood loss during surgery.

3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain.

4. The client is sleeping to avoid pain associated with surgery.

Correct Answer: 3

Rationale 1: Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client.

Rationale 2: Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client.

Rationale 3: Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client.

Rationale 4: Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client.

Global Rationale: Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 15.6 Plan nursing care for an infant or child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies.

Question 16

Type: MCSA

The nurse is working with a preschool-age client in Bryant traction for a fractured femur. Why is the Oucher Scale useful to the nurse caring for this child?

1. It provides continuity and consistency in assessing and monitoring the childs pain.

2. It decreases anxiety in the child.

3. It increases the childs comfort level.

4. It reduces the childs fear of painful procedures.

Correct Answer: 1

Rationale 1: Pain assessment scales are used to assess and monitor pain. Using an assessment scale cannot reduce the childs anxiety or fear, nor can it increase the childs comfort level. The nurse can reduce anxiety or fear and increase the childs comfort level by implementing appropriate nursing interventions based on assessment scale data.

Rationale 2: Pain assessment scales are used to assess and monitor pain. Using an assessment scale cannot reduce the childs anxiety or fear, nor can it increase the childs comfort level. The nurse can reduce anxiety or fear and increase the childs comfort level by implementing appropriate nursing interventions based on assessment scale data.

Rationale 3: Pain assessment scales are used to assess and monitor pain. Using an assessment scale cannot reduce the childs anxiety or fear, nor can it increase the childs comfort level. The nurse can reduce anxiety or fear and increase the childs comfort level by implementing appropriate nursing interventions based on assessment scale data.

Rationale 4: Pain assessment scales are used to assess and monitor pain. Using an assessment scale cannot reduce the childs anxiety or fear, nor can it increase the childs comfort level. The nurse can reduce anxiety or fear and increase the childs comfort level by implementing appropriate nursing interventions based on assessment scale data.

Global Rationale: Pain assessment scales are used to assess and monitor pain. Using an assessment scale cannot reduce the childs anxiety or fear, nor can it increase the childs comfort level. The nurse can reduce anxiety or fear and increase the childs comfort level by implementing appropriate nursing interventions based on assessment scale data.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 15.3 Assess the developmental abilities of children to perform a self-assessment of pain intensity.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

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