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. What is the recommended method to assess hydration status in infants?

Correct answer: C

Rationale: The correct answer is C: Urine output. Assessing urine output is a recommended method to determine hydration status in infants. Adequate urine output indicates good hydration, while decreased urine output may suggest dehydration. Capillary refill time (Choice A) is more indicative of circulatory status rather than hydration. Skin turgor (Choice B) is a useful assessment in adults but can be less reliable in infants. Checking mucous membranes (Choice D) can provide some information on hydration, but it is not as reliable as assessing urine output in infants.

3. At which age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?

Correct answer: B

Rationale: Infants typically begin to smile in response to pleasurable stimuli by 2 months, which is an early sign of social interaction and emotional development.

4. Which action should the nurse implement when taking an axillary temperature?

Correct answer: C

Rationale: The correct technique involves placing the thermometer tip in the center of the axilla to ensure an accurate reading, with the arm held close to the body.

5. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.)

Correct answer: A

Rationale: Hypernatremia typically presents with lethargy, oliguria, and intense thirst due to the body's attempt to conserve water. Apathy can also occur, but lethargy and thirst are more consistent indicators.

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