A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use? a. FACES b. Numeric c. CRIES d.Visual analog✔✔✔ A. The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management.
A nurse is planning an educational program to teach parents about pro- tecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. “allow your child to play outside during the hours between 10:00am and 2:00pm.” b. “choose a waterproof sunscreen with a minimum SPF of 15.” 1 / 4 2 / 18 c. “dress you child in loose weave polyester fabric prior to sun exposure.” d. “reapply sunscreen every 4 hours.”✔✔✔ B. The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn.
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? a. an 18 month old toddler who has unintelligible speech b. a 3 month old infant who has exaggerated startle response c. a 4 year old preschooler who prefers playing with others rather than alone d. an 8 month old infant who is not yet making babbling sounds✔✔✔ D. The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing.
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a. HR 124 2 / 4 3 / 18 b. increased tear production 3 / 4 4 / 18 c. sunken anterior fontanel d. capillary refill 2 seconds✔✔✔ C. The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching? a. “limit movement of the child’s large joints” b. “encourage the child to perform independent self-care.” c. “provide the child with a soft mattress for sleeping.” d. “schedule a 2 hour daily nap for the child in the afternoon.”✔✔✔ B. The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child’s pain while maximizing mobility. Encouraging and praising the child’s efforts for independence will also increase their self-esteem.
A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. use sterile scissors to remove the dressing from the site b. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use
