Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a 4-year-old child following a surgical procedure. Which of the following pain rating scales should the nurse use?
A. Oucher pain rating scale
Oucher pain rating scale: The Oucher pain rating scale uses pictures of children's faces to represent varying degrees of pain intensity. This scale is specifically designed for young children and can be effective in assessing pain in preschool-aged children who may not yet be able to accurately use verbal descriptors to express their pain.
B. Word-Graphic rating scale
Word-Graphic rating scale: This type of scale presents both words and pictures to represent different levels of pain intensity. While it may be suitable for older children who can understand and use words to describe their pain, it may be less effective for a 4-year-old child who is still developing language skills.
C. Numeric rating scale
Numeric rating scale: Numeric rating scales typically ask the child to rate their pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. While this scale may be appropriate for older children, it may be challenging for a 4-year-old to understand and use numbers to describe their pain.
D. Visual analog scale
Visual analog scale: Visual analog scales typically consist of a line with endpoints labeled "no pain" and "worst pain imaginable," with the child asked to mark or point to the spot on the line that represents their pain level. While this scale may be suitable for older children and adults, it may be too abstract for a 4-year-old child to understand and use effectively.
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Full Explanation
A. Oucher pain rating scale: The Oucher pain rating scale uses pictures of children's faces to represent varying degrees of pain intensity. This scale is specifically designed for young children and can be effective in assessing pain in preschool-aged children who may not yet be able to accurately use verbal descriptors to express their pain.
B. Word-Graphic rating scale: This type of scale presents both words and pictures to represent different levels of pain intensity. While it may be suitable for older children who can understand and use words to describe their pain, it may be less effective for a 4-year-old child who is still developing language skills.
C. Numeric rating scale: Numeric rating scales typically ask the child to rate their pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. While this scale may be appropriate for older children, it may be challenging for a 4-year-old to understand and use numbers to describe their pain.
D. Visual analog scale: Visual analog scales typically consist of a line with endpoints labeled "no pain" and "worst pain imaginable," with the child asked to mark or point to the spot on the line that represents their pain level. While this scale may be suitable for older children and adults, it may be too abstract for a 4-year-old child to understand and use effectively.
Similar Questions
A nurse is assessing a child who has acute kidney injury. Which of the following clinical manifestations should the nurse expect?
A. Decreased respiratory rate
Decreased respiratory rate: AKI typically does not directly affect respiratory rate. Respiratory rate is more closely related to lung function and oxygenation status rather than kidney function.
B. Polyuria
Polyuria: This is an incorrect option. Polyuria, or increased urine output, is not typically seen in acute kidney injury. In fact, oliguria (decreased urine output) or anuria (absence of urine output) are more common in AKI due to decreased kidney function.
C. Hyperactivity
Hyperactivity: AKI does not typically cause hyperactivity. In fact, children with AKI may appear lethargic or fatigued due to the buildup of waste products in their bodies and electrolyte imbalances.
D. Edema
Edema: This is the correct option. Edema, or swelling due to fluid retention, is a common clinical manifestation of AKI. When the kidneys are unable to adequately filter and excrete excess fluid from the body, fluid accumulates in the tissues, leading to edema. Edema may be particularly noticeable in the face, hands, feet, or around the eyes.
Full Explanation
A. Decreased respiratory rate: AKI typically does not directly affect respiratory rate. Respiratory rate is more closely related to lung function and oxygenation status rather than kidney function.
B. Polyuria: This is an incorrect option. Polyuria, or increased urine output, is not typically seen in acute kidney injury. In fact, oliguria (decreased urine output) or anuria (absence of urine output) are more common in AKI due to decreased kidney function.
C. Hyperactivity: AKI does not typically cause hyperactivity. In fact, children with AKI may appear lethargic or fatigued due to the buildup of waste products in their bodies and electrolyte imbalances.
D. Edema: This is the correct option. Edema, or swelling due to fluid retention, is a common clinical manifestation of AKI. When the kidneys are unable to adequately filter and excrete excess fluid from the body, fluid accumulates in the tissues, leading to edema. Edema may be particularly noticeable in the face, hands, feet, or around the eyes.
A nurse is providing teaching to the parent of a school-age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching?
A. "Seal nonwashable items in a plastic bag for 2 days."
"Seal nonwashable items in a plastic bag for 2 days."This instruction is incorrect. Items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for two weeks.
B. "Soak hair brushes in boiling water for 10 minutes."
"Soak hair brushes in boiling water for 10 minutes." This is correct. According to CDC, combs and brushes should be soaked in hot water (at least 130 degrees fahrenheit) to help avoid re-infestation.
C. "Apply permethrin 1 percent cream rinse every day for 5 days."
"Apply permethrin 1 percent cream rinse every day for 5 days." This instruction is incorrect. Permethrin 1 percent cream rinse is a medication used to treat head lice infestations, but it is typically applied only once and then rinsed out after a specified period of time (usually 10 minutes). Repeated daily application for five days is not recommended and may lead to unnecessary exposure to the medication.
D. "After washing bed linens, place them in a dryer on a cool setting for 30 minutes."
"After washing bed linens, place them in a dryer on a cool setting for 30 minutes."This instruction is incorrect. To effectively kill lice and nits on bed linens, they should be washed in hot water (at least 130°F or 54°C) and then dried on a hot setting in the dryer. A cool setting may not be sufficient to kill lice and nits.
Full Explanation
A. "Seal nonwashable items in a plastic bag for 2 days."
This instruction is incorrect. Items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for two weeks
B. "Soak hair brushes in boiling water for 10 minutes." This is correct. According to CDC, combs and brushes should be soaked in hot water (at least 130 degrees fahrenheit) to help avoid re-infestation.
C. "Apply permethrin 1 percent cream rinse every day for 5 days."
This instruction is incorrect. Permethrin 1 percent cream rinse is a medication used to treat head lice infestations, but it is typically applied only once and then rinsed out after a specified period of time (usually 10 minutes). Repeated daily application for five days is not recommended and may lead to unnecessary exposure to the medication.
D. "After washing bed linens, place them in a dryer on a cool setting for 30 minutes."
This instruction is incorrect. To effectively kill lice and nits on bed linens, they should be washed in hot water (at least 130°F or 54°C) and then dried on a hot setting in the dryer. A cool setting may not be sufficient to kill lice and nits.
A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse not report to the provider?
A. The infant does not exhibit fear of strangers.
This is a normal social behavior for a 6-month-old infant. Infants usually develop stranger anxiety between 8 and 12 months of age, when they become more aware of their surroundings and attachment figures.
B. The infant does not roll over from his abdomen to his back.
By 6 months of age, most infants can roll over in both directions- from their abdomen to their back and vice versa. The inability to roll over from abdomen to back may indicate a delay in gross motor skills development. This finding should be reported to the healthcare provider for further evaluation.
C. The infant does not pick up objects from the floor with his fingers.
The infant does not pick up objects from the floor with his fingers. By 6 months of age, infants typically begin to develop the ability to grasp and pick up objects using their fingers. This milestone is part of fine motor skills development. The inability to pick up objects from the floor with fingers may indicate a delay in fine motor skills and should be reported to the provider for further assessment.
D. The infant does not sit on the floor unsupported.
The infant does not sit on the floor unsupported.By 6 months of age, infants typically begin to develop the ability to sit unsupported for short periods. While some variability exists in when infants achieve this milestone, the inability to sit unsupported at 6 months may indicate a delay in gross motor skills development. This finding should be reported to the provider for further evaluation.
E. None
None
F. None
None
Full Explanation
A. The infant does not exhibit fear of strangers.
The infant does not exhibit fear of strangers is not a finding that the nurse should report to the provider, as this is a normal social behavior for a 6-month-old infant. Infants usually develop stranger anxiety between 8 and 12 months of age, when they become more aware of their surroundings and attachment figures.
B. The infant does not roll over from his abdomen to his back.
By 6 months of age, most infants can roll over in both directions— from their abdomen to their back and vice versa. The inability to roll over from abdomen to back may indicate a delay in gross motor skills development. This finding should be reported to the healthcare provider for further evaluation.
C. The infant does not pick up objects from the floor with his fingers.
By 6 months of age, infants typically begin to develop the ability to grasp and pick up objects using their fingers. This milestone is part of fine motor skills development. The inability to pick up objects from the floor with fingers may indicate a delay in fine motor skills and should be reported to the provider for further assessment.
D. The infant does not sit on the floor unsupported.
By 6 months of age, infants typically begin to develop the ability to sit unsupported for short periods. While some variability exists in when infants achieve this milestone, the inability to sit unsupported at 6 months may indicate a delay in gross motor skills development. This finding should be reported to the provider for further evaluation.