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

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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. After a 7-year-old with acute diarrhea has been rehydrated with oral rehydration solutions, what type of diet should the nurse recommend following rehydration?

Correct answer: A

Rationale: After rehydration, a regular diet is generally recommended to ensure proper nutrition and recovery. A regular diet includes a balanced intake of all food groups and nutrients. Fruit juices may be too high in simple sugars and lack necessary nutrients, which can exacerbate diarrhea. While a high carbohydrate diet may be beneficial in some cases, a regular diet is more comprehensive. The BRAT diet, consisting of bananas, rice, apples, and toast or tea, was previously recommended for diarrhea, but it lacks adequate protein and fat, so a regular diet is now preferred for overall better nutrition and recovery.

3. Why are neonates predisposed to problems with thermoregulation?

Correct answer: C

Rationale: Neonates have a large surface area relative to their weight, which makes them prone to heat loss to the environment, leading to thermoregulation issues. The underdeveloped kidney affecting urine concentration (Choice A) is unrelated to the thermal regulation process. While a flexed posture can help retain heat (Choice B), it does not outweigh the impact of the large body surface area in neonates. Although subcutaneous fat (Choice D) provides insulation, in neonates, the large body surface area is more significant in contributing to heat loss than the fat's insulating properties.

4. Which of the following is a key feature of autism spectrum disorder?

Correct answer: A

Rationale: Delayed speech development is a significant feature of autism spectrum disorder. Many children with autism exhibit delays in speech and language development, which can be one of the early signs of the condition. Hyperactivity, lack of interest in toys, and aggressive behavior are not key defining features of autism spectrum disorder. While some individuals with autism may exhibit these behaviors, they are not universally characteristic of the disorder.

5. The nurse is presenting a staff development program about understanding culture in the healthcare encounter. Which components should the nurse include in the program? (Select all that apply.)

Correct answer: B

Rationale: Cultural humility, sensitivity, and competency are key components in providing culturally competent care in healthcare encounters.

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