Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a 4-year-old child following an orthopaedic procedure. When assessing the child for pain, which of the following pain scales should the nurse use?
A. FACES.
The FACES pain scale is a self-report tool that uses six facial expressions to indicate different levels of pain. It is suitable for children aged 3 to 13 years who can match their pain to a face. The nurse should use this scale to assess the pain of a 4-year-old child following an orthopedic procedure.
B. Word-graphic.
Word-graphic is wrong because it is a pain scale that uses words and pictures to describe pain intensity. It is suitable for children aged 8 to 17 years who can read and understand words.
C. Numeric.
Numeric is wrong because it is a pain scale that uses numbers from 0 to 10 to rate pain intensity. It is suitable for children aged 5 years and older who can understand numbers and concepts of more or less.
D. CRIES.
CRIES is wrong because it is a pain scale that uses five behavioural indicators (crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness) to measure pain in neonates. It is suitable for infants aged 0 to 6 months who cannot communicate verbally.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
The FACES pain scale is a self-report tool that uses six facial expressions to indicate different levels of pain. It is suitable for children aged 3 to 13 years who can match their pain to a face. The nurse should use this scale to assess the pain of a 4-year-old child following an orthopaedic procedure.
Choice B. Word-graphic is wrong because it is a pain scale that uses words and pictures to describe pain intensity.
It is suitable for children aged 8 to 17 years who can read and understand words.
Choice C. Numeric is wrong because it is a pain scale that uses numbers from 0 to 10 to rate pain intensity. It is suitable for children aged 5 years and older who can understand numbers and concepts of more or less.
Choice D. CRIES is wrong because it is a pain scale that uses five behavioural indicators (crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness) to measure pain in neonates.
It is suitable for infants aged 0 to 6 months who cannot communicate verbally.
Similar Questions
A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin.
Which of the following outcomes indicates that the client is adhering to the medication regimen?
A. The client tests negative for HIV.
Choice A is wrong because testing negative for HIV does not indicate that the client is adhering to the medication regimen for tuberculosis. HIV testing is not related to tuberculosis treatment.
B. The client has a negative sputum culture.
The client has a negative sputum culture. This indicates that the client is adhering to the medication regimen because a negative sputum culture means that the client is no longer infectious and has cleared the tuberculosis bacteria from their lungs.
C. The client’s liver function test results are within the expected reference range.
Choice C is wrong because having a positive purified protein derivative test does not indicate that the client is adhering to the medication regimen for tuberculosis. A positive PPD test means that the client has been exposed to tuberculosis, but it does not indicate whether the client has active or latent infection.
D. The client has a positive purified protein derivative test.
Choice D is wrong because having liver function test results within the expected reference range does not indicate that the client is adhering to the medication regimen for tuberculosis. Liver function tests are used to monitor for possible adverse effects of isoniazid and rifampin, which can cause hepatotoxicity, but they do not reflect the effectiveness of the treatment.
Full Explanation
The client has a negative sputum culture. This indicates that the client is adhering to the medication regimen because a negative sputum culture means that the client is no longer infectious and has cleared the tuberculosis bacteria from their lungs.
Choice A is wrong because testing negative for HIV does not indicate that the client is adhering to the medication regimen for tuberculosis. HIV testing is not related to tuberculosis treatment.
Choice C is wrong because having a positive purified protein derivative test does not indicate that the client is adhering to the medication regimen for tuberculosis.
A positive PPD test means that the client has been exposed to tuberculosis, but it does not indicate whether the client has an active or latent infection. Choice D is wrong because having liver function test results within the expected reference range does not indicate that the client is adhering to the medication regimen for tuberculosis.
Liver function tests are used to monitor for possible adverse effects of isoniazid and rifampin, which can cause hepatotoxicity, but they do not reflect the effectiveness of the treatment.
A nurse is planning care for a client who is receiving morphine via continuous epidural infusion.
The nurse should monitor the client for which of the following adverse effects?
A. Gastric bleeding.
Choice A is wrong because gastric bleeding is not a common adverse effect of morphine administered via continuous epidural infusion. Gastric bleeding can occur due to peptic ulcer disease, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticoagulants.
B. Pruritus.
Pruritus is a common adverse effect of morphine administered via continuous epidural infusion. It is caused by the release of histamine from mast cells in the skin. Pruritus can be treated with antihistamines or opioid antagonists. Choice A is wrong because gastric bleeding is not a common adverse effect of morphine administered via continuous epidural infusion.
C. Cough.
Choice C is wrong because the cough is not a common adverse effect of morphine administered via continuous epidural infusion. Cough can be caused by respiratory infections, asthma, or chronic obstructive pulmonary disease (COPD).
D. Tachypnea.
Choice D is wrong because tachypnea is not a common adverse effect of morphine administered via continuous epidural infusion. Tachypnea can be caused by hypoxia, anxiety, pain, or fever. Morphine can cause respiratory depression, which is characterized by bradypnea, not tachypnea.
Full Explanation
Gastric bleeding can occur due to peptic ulcer disease, nonsteroidal anti inflammatory drugs (NSAIDs), or anticoagulants.
Choice C is wrong because cough is not a common adverse effect of morphine administered via continuous epidural infusion.
Cough can be caused by respiratory infections, asthma, or chronic obstructive pulmonary disease (COPD).
Choice D is wrong because tachypnea is not a common adverse effect of morphine administered via continuous epidural infusion.
Tachypnea can be caused by hypoxia, anxiety, pain, or fever. Morphine can cause respiratory depression, which is characterized by bradypnea, not tachypnea.
A nurse is administering 4 mg of hydromorphone to a client by mouth every 4 hr. The medication is provided as hydromorphone 8 mg per tablet. Which of the following actions is appropriate for the nurse to take?
A. Store the remaining half of the pill in the automated medication dispensing system.
Choice A is wrong because storing the remaining half of the pill in the automated medication dispensing system could lead to errors in dosage or diversion of the drug.
B. Dispose of the remaining medication while another nurse observes.
This is because hydromorphone is a controlled substance and any unused portion should be discarded in the presence of a witness. Some possible explanations for the other choices are:
C. Return the remaining medication to the facility’s pharmacy.
Choice C is wrong because returning the remaining medication to the facility’s pharmacy is not a recommended practice for controlled substances and could also result in errors or diversion.
D. Place the remaining half of the pill in the unit-dose package.
Choice D is wrong because placing the remaining half of the pill in the unit-dose package could compromise the integrity and stability of the medication and expose it to environmental factors. Normal ranges for hydromorphone are not applicable as it is a synthetic opioid analgesic that does not have a therapeutic level. However, some factors that may affect its pharmacokinetics and pharmacodynamics are age, weight, renal function, liver function, genetic polymorphisms, and drug interactions.
Full Explanation
This is because hydromorphone is a controlled substance and any unused portion should be discarded in the presence of a witness. Some possible explanations for the other choices are:
Choice A is wrong because storing the remaining half of the pill in the automated medication dispensing system could lead to errors in dosage or diversion of the drug.
Choice C is wrong because returning the remaining medication to the facility’s pharmacy is not a recommended practice for controlled substances and could also result in errors or diversion.
Choice D is wrong because placing the remaining half of the pill in the unit-dose package could compromise the integrity and stability of the medication and expose it to environmental factors.
Normal ranges for hydromorphone are not applicable as it is a synthetic opioid analgesic that does not have a therapeutic level.
However, some factors that may affect its pharmacokinetics and pharmacodynamics are age, weight, renal function, liver function, genetic polymorphisms, and drug interactions.