Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data regarding the pain level of a 3-year-old child on the second postoperative day following an appendectomy.
Which of the following actions should the nurse take?
A. Use the FACES Scale to assess the child's pain level.
Use the FACES Scale to assess the child's pain level. Rationale: The FACES Scale is a suitable pain assessment tool for a 3-year-old child. It uses facial expressions to assess pain intensity, making it a child-friendly and reliable option for assessing pain in young children who may have difficulty using numeric or visual analog scales.
B. Use a numeric scale to assess the child's pain level.
Use a numeric scale to assess the child's pain level. Rationale: Using a numeric pain scale may not be appropriate for a 3-year-old child, as they may have limited understanding of numbers and may struggle to express their pain using this method. The FACES Scale or other age-appropriate tools are more effective for this age group.
C. Use the Visual Analog Scale to assess the child's pain level.
Use the Visual Analog Scale to assess the child's pain level. Rationale: The Visual Analog Scale typically involves a line with endpoints representing "no pain" and "worst pain," and the child is asked to mark their pain level on the line. This scale may be challenging for a 3-year-old child to use effectively, as it requires a level of abstract thinking and
D. Use a color tool to assess the child's pain level.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom T1 PM Summer 2023 Proctored Exam 5. Take the full exam now
Similar Questions
A nurse is reinforcing discharge teaching with a client about medications.
Which of the following client statements indicate an understanding?
A. "I will discard unused narcotic medications in a trash container.".
The statement, "I will discard unused narcotic medications in a trash container," indicates a lack of understanding. Disposing of unused narcotic medications in a regular trash container is not safe and can lead to accidental ingestion or misuse by others. Proper disposal methods should be explained.
B. "I will store narcotic medications in the original package.".
This statement, "I will store narcotic medications in the original package," indicates an understanding of safe medication storage. Keeping narcotic medications in their original packaging helps in proper identification and prevents accidental ingestion by others. It also allows the client to access important information such as dosage instructions and expiration dates.
C. "I will obtain my prescribed medications from different pharmacies.".
The statement, "I will obtain my prescribed medications from different pharmacies," suggests a potential misunderstanding. Consistently using one pharmacy for all prescriptions is recommended to help monitor for drug interactions and prevent duplications or contraindications that can occur when using multiple pharmacies.
D. "I will store over-the-counter medications in an unlocked cabinet under a sink.".
The statement, "I will store over-the-counter medications in an unlocked cabinet under a sink," indicates a lack of understanding. Storing medications, whether prescription or over-the-counter, in an unlocked cabinet under a sink is not safe, as it allows easy access to medications by children or others who should not have them. Medications should be stored securely out of reach and in a cool, dry place.
A nurse is reinforcing teaching with a client who has diabetes mellitus about diabetic retinopathy.
Which of the following statements should the nurse make?
A. "It is caused by an increase in intraocular pressure.".
The statement, "It is caused by an increase in intraocular pressure," is not accurate. Diabetic retinopathy is caused by damage to the blood vessels in the retina due to prolonged high blood sugar levels, not increased intraocular pressure. This choice is incorrect.
B. "Seeing spots is a manifestation of diabetic retinopathy.".
The statement, "Seeing spots is a manifestation of diabetic retinopathy," is not entirely accurate. Seeing spots or floaters in the vision can be a symptom of diabetic retinopathy, but it is not a comprehensive description of the condition. This choice is partially correct but lacks specificity.
C. "Have an eye exam every 2 years.".
The statement, "Have an eye exam every 2 years," is not accurate in the context of diabetic retinopathy. Individuals with diabetes should have more frequent eye exams, typically annually, to monitor for the development or progression of diabetic retinopathy. This choice is incorrect.
D. "Clouding of the lens is a manifestation of diabetic retinopathy.".
The statement, "Clouding of the lens is a manifestation of diabetic retinopathy," is not accurate. Clouding of the lens is a characteristic of cataracts, not diabetic retinopathy. This choice is incorrect.
A nurse is assisting with teaching a newly licensed nurse about pain.
Which of the following is an example of acute pain?
A. Fibromyalgia.
Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, not acute pain. This choice is incorrect.
B. Surgical incision.
A surgical incision represents an example of acute pain. Acute pain typically has a sudden onset and is time-limited, often resulting from tissue injury or a medical procedure. This choice is correct.
C. Peripheral neuropathy.
Peripheral neuropathy is a chronic condition characterized by nerve damage and is associated with chronic pain, not acute pain. This choice is incorrect.
D. Rheumatoid arthritis.
Rheumatoid arthritis is a chronic autoimmune disease that can cause chronic joint pain and inflammation, not acute pain. This choice is incorrect.