during the nurses initial assessment of a school age child the child reports a pain level of 6 out of 10 the child is lying quietly in bed watching te
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. During the nurse’s initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. What action should the nurse take?

Correct answer: B

Rationale: Pain management should be based on the child’s report of pain, regardless of their activity level. Administering the prescribed analgesic is the appropriate action. Reassessing the child in 15 minutes without providing immediate pain relief may not be in the child's best interest. Doing nothing since the child appears to be resting may lead to inadequate pain management. Asking the child’s parents if they think the child is hurting does not replace the need for direct assessment and intervention by the nurse.

2. Which should the nurse teach to parents regarding oral health of children? (Select all that apply.)

Correct answer: C

Rationale: Fluoridated water helps prevent caries, early childhood caries is preventable, and dental hygiene should start with the first tooth eruption.

3. The nurse is testing an infant's visual acuity. By which age should the infant be able to fix on and follow a target?

Correct answer: C

Rationale: By 3 to 4 months of age, an infant should be able to fix on and follow a target, indicating proper visual development.

4. The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?

Correct answer: D

Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.

5. The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for?

Correct answer: C

Rationale: Common complications of activated charcoal administration include diarrhea and vomiting. Intestinal obstruction can occur if the charcoal forms a mass in the intestines. Fluid retention is less likely and not typically a complication associated with activated charcoal.

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