the nurse is caring for a 4 year old client what is the most appropriate pain scale for the nurse to use during the assessment

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?

A. McGill Pain Scale
B. FLACC Pain Scale
C. CRIES Pain Scale
D. Wong-Baker Pain Scale

Correct answer: D

Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.

2. Health promotion activities are designed to help clients:

A. reduce the risk of illness
B. maintain maximal function
C. promote healthy habits related to healthcare
D. all of the above

Correct answer: D

Rationale: Health promotion activities encompass a broad range of interventions aimed at enhancing overall well-being. These activities not only focus on reducing the risk of illness but also on maintaining maximal function and promoting healthy habits related to healthcare. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all integral components of health promotion strategies, emphasizing the multidimensional approach required to support clients in achieving optimal health outcomes.

3. An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?

A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours.
B. Ask the registered nurse to obtain a prescription for a nighttime sedative.
C. Report the findings to the registered nurse.
D. Document the findings in the medical record.

Correct answer: D

Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Since the reported data are normal age-related changes, the appropriate action for the nurse would be to document the findings in the medical record. Reporting the findings to the registered nurse is unnecessary as these changes are expected with aging and do not indicate a need for immediate intervention. Prescribing sedatives should be avoided as a first-line approach due to potential side effects and risks, especially in older adults. Encouraging the consumption of stimulants like caffeinated beverages during the daytime may further disrupt sleep patterns, which is counterproductive in addressing the client's reported sleep issues.

4. When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:

A. "Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse."?
B. "Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse."?
C. "The average time it takes someone your age to conceive is 5.3 months, so if you haven't conceived by then, we can refer you."?
D. "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year."?

Correct answer: D

Rationale: The best response in this scenario is to offer immediate guidance while also indicating when fertility counseling should be sought. While Choice A is technically correct as guidelines recommend seeking fertility counseling after 1 year of unprotected intercourse, it lacks providing immediate guidance. Choice B suggests seeking counseling after 6-9 months, which is earlier than the standard recommendation of 1 year. Choice C mentions the average time to conceive for someone of the client's age without addressing the client's current concern. Therefore, Choice D is the most appropriate response as it offers immediate guidance along with a plan for referral if needed.

5. What is one of the main goals of Healthy People 2010?

A. reduction of health care costs
B. elimination of health disparities
C. investigation of substance abuse
D. determination of an acceptable morbidity rate

Correct answer: C

Rationale: The main goal of Healthy People 2010 is the elimination of health disparities among the U.S. population. This initiative outlines specific objectives to improve the overall health of Americans by addressing disparities in health outcomes. Choice A, reduction of health care costs, is not the primary goal of Healthy People 2010, although it may be a beneficial outcome. Choice C, investigation of substance abuse, is not a main goal of Healthy People 2010; while substance abuse may be a factor in health disparities, the primary focus is on broader disparities. Choice D, determination of an acceptable morbidity rate, is not the main focus of Healthy People 2010; instead, it aims to address health disparities in different population groups.