Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 12-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis. The child rates pain as 10/10 but refuses IV opioids due to fear of needles. Which intervention should the nurse implement FIRST?
A. Document the refusal and delay analgesia.
Delaying pain management is not appropriate in a child experiencing a vaso-occlusive crisis. Pain relief is a priority nursing intervention, and documenting refusal without offering alternatives does not address the child’s suffering.
B. Explain that pain medication is mandatory.
Forcing medication or implying it is mandatory can increase the child’s fear and anxiety, potentially worsening pain and reducing cooperation. It is not a therapeutic approach and does not respect the child’s autonomy.
C. Ask the child to wait until the pain becomes severe.
Waiting is unsafe and unethical. A pain score of 10/10 indicates severe pain that requires prompt management. Delaying treatment can increase the risk of pain-related complications, including stress-induced vaso-occlusion or prolonged crisis.
D. Offer nonpharmacologic pain.
Since the child refuses IV opioids due to fear of needles, the nurse should first implement alternative strategies while respecting the child’s autonomy. Nonpharmacologic interventions for sickle cell pain include distraction techniques such as videos, games, or music, guided imagery or relaxation exercises, heat application to affected joints, and deep breathing exercises. These approaches can reduce anxiety and pain perception and can be used immediately while exploring other analgesic options, such as oral opioids, patient-controlled analgesia, or topical analgesics.
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Full Explanation
A. Delaying pain management is not appropriate in a child experiencing a vaso-occlusive crisis. Pain relief is a priority nursing intervention, and documenting refusal without offering alternatives does not address the child’s suffering.
B. Forcing medication or implying it is mandatory can increase the child’s fear and anxiety, potentially worsening pain and reducing cooperation. It is not a therapeutic approach and does not respect the child’s autonomy.
C. Waiting is unsafe and unethical. A pain score of 10/10 indicates severe pain that requires prompt management. Delaying treatment can increase the risk of pain-related complications, including stress-induced vaso-occlusion or prolonged crisis.
D. Since the child refuses IV opioids due to fear of needles, the nurse should first implement alternative strategies while respecting the child’s autonomy. Nonpharmacologic interventions for sickle cell pain include distraction techniques such as videos, games, or music, guided imagery or relaxation exercises, heat application to affected joints, and deep breathing exercises. These approaches can reduce anxiety and pain perception and can be used immediately while exploring other analgesic options, such as oral opioids, patient-controlled analgesia, or topical analgesics.
Similar Questions
The patient has an order for a single dose of ceftriaxone 400 mg IM. The final concentration is 500 mg/1.2 ml. How many milliliters will you administer? (Round to the nearest hundredth.)
Full Explanation
Ordered dose = 400 mg
Available = 500 mg in 1.2 mL
Step 1: Use the formula
Volume to administer = (Ordered dose ÷ Available dose) × Volume available
Step 2: Substitute the values
Volume = (400 ÷ 500) × 1.2
Step 3: Calculate
Volume = 0.8 × 1.2 = 0.96 mL
A 9-month-old infant presents with fever and irritability. The nurse notices the infant repeatedly pulls at the right ear, arches the back when touched, and grimaces during diaper changes. Which assessment BEST guides the nurse's interpretation of the infant's pain?
A. Behavioral cues, posture, and expressions help infer pain location and intensity.
Infants cannot verbally communicate pain, so nurses rely on observational cues. Pulling at the ear, arching the back, grimacing, and irritability are valid behavioral indicators of pain and help guide assessment of location and severity. Combining these with physiological signs, such as increased heart rate or changes in respiratory pattern, provides a comprehensive understanding of the infant’s pain.
B. Only physiological indicators reliably determine the presence and location of pain.
Physiological indicators like tachycardia, hypertension, or increased respiratory rate are nonspecific and may reflect stress, fever, or other illness, so relying solely on them is inadequate for pain assessment.
C. The infant's behaviors show generated distress: cannot locate pain without verbalization.
Infants cannot verbalize pain, but behavioral cues are well-recognized and validated indicators of pain. Assuming pain cannot be assessed without speech is inaccurate.
D. The infant's behaviors are exaggerated due to caregiver anxiety and attention-seeking.
Infants do not exhibit pain behaviors to manipulate caregivers. Behaviors such as ear pulling, back arching, and grimacing are genuine indicators of discomfort or pain and should be taken seriously.
Full Explanation
A. Infants cannot verbally communicate pain, so nurses rely on observational cues. Pulling at the ear, arching the back, grimacing, and irritability are valid behavioral indicators of pain and help guide assessment of location and severity. Combining these with physiological signs, such as increased heart rate or changes in respiratory pattern, provides a comprehensive understanding of the infant’s pain.
B. Physiological indicators like tachycardia, hypertension, or increased respiratory rate are nonspecific and may reflect stress, fever, or other illness, so relying solely on them is inadequate for pain assessment.
C. Infants cannot verbalize pain, but behavioral cues are well-recognized and validated indicators of pain. Assuming pain cannot be assessed without speech is inaccurate.
D. Infants do not exhibit pain behaviors to manipulate caregivers. Behaviors such as ear pulling, back arching, and grimacing are genuine indicators of discomfort or pain and should be taken seriously.
A nurse is assessing a 3-year-old child's response to a new daycare environment. The child initially clings to the parent, cries, and takes several minutes to warm up to other children and new activities. Which statement BEST reflects the child's temperament?
A. The child's behavior indicates a delay in social development rather than temperament.
The behaviors described including initial clinginess, crying, and gradual adjustment, are typical variations in temperament, not indicators of a social developmental delay. Most 3-year-olds show a range of responses when exposed to new environments.
B. The child has a difficult temperament and is unlikely to ever adapt to new environments.
A difficult temperament is characterized by intense reactions, irregular routines, and high sensitivity, but the child in this scenario eventually warms up and engages with others, indicating the child is not persistently difficult.
C. The child has an easy temperament and adapts quickly to new situations.
Children with an easy temperament adjust rapidly, show positive mood, and require minimal guidance, which does not match the initial clinginess and crying observed in this child.
D. The child has a slow-to-warm-up temperament and requires time to adjust to new experiences.
Slow-to-warm-up children are cautious in unfamiliar situations, may initially withdraw or cling, and gradually adapt once they feel safe. The child’s behavior of crying, clinging, and taking several minutes to engage aligns with this temperament type.
Full Explanation
A. The behaviors described including initial clinginess, crying, and gradual adjustment, are typical variations in temperament, not indicators of a social developmental delay. Most 3-year-olds show a range of responses when exposed to new environments.
B. A difficult temperament is characterized by intense reactions, irregular routines, and high sensitivity, but the child in this scenario eventually warms up and engages with others, indicating the child is not persistently difficult.
C. Children with an easy temperament adjust rapidly, show positive mood, and require minimal guidance, which does not match the initial clinginess and crying observed in this child.
D. Slow-to-warm-up children are cautious in unfamiliar situations, may initially withdraw or cling, and gradually adapt once they feel safe. The child’s behavior of crying, clinging, and taking several minutes to engage aligns with this temperament type.