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
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. 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.

2. The nurse is teaching a child experiencing severe edema associated with minimal change nephrotic syndrome about his diet. The nurse should discuss what dietary need?

Correct answer: C

Rationale: Fluid restriction is often necessary to manage severe edema associated with MCNS. Increasing protein is not typically recommended due to the risk of exacerbating proteinuria, and calorie reduction is not generally needed.

3. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

Correct answer: D

Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.

4. What statement is an advantage of peritoneal dialysis compared with hemodialysis?

Correct answer: C

Rationale: Peritoneal dialysis is generally easier to learn and can be safely performed at home. Although dietary limitations still apply, this method offers greater flexibility in treatment scheduling compared to hemodialysis, which often requires multiple weekly visits to a dialysis center.

5. Which laboratory value at the time of diagnosis should the nurse anticipate would determine the worst prognosis for a child with leukemia?

Correct answer: D

Rationale: A high white blood cell count (leukocytes of 275,000/mcL) at diagnosis is associated with a worse prognosis in leukemia because it indicates a more aggressive disease with a higher tumor burden. Slow response to chemotherapy (choice A) is a consequence of the aggressive disease and not a determining factor at diagnosis. Platelets of 150,000/mcL (choice B) and leukocytes less than 10,000/mcL (choice C) are within normal ranges and not indicative of a worse prognosis in leukemia.

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