the nurse is educating a new nurse on identification of pain in children what does the nurse teach about physiologic measurements in childrens pain as
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?

Correct answer: A

Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.

2. The nurse is providing education to the parent of a child with Beta-thalassemia. Which risk factors about the condition should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D: Chronic hypoxia and iron overload. Children with Beta-thalassemia often suffer from chronic hypoxia due to ineffective erythropoiesis and require frequent blood transfusions, leading to iron overload. These complications must be managed to prevent organ damage. Choices A, B, and C are incorrect. Hypertrophy of the thyroid, polycythemia vera, and thrombocytopenia are not direct risk factors associated with Beta-thalassemia. Therefore, they should not be included in the teaching regarding this condition.

3. At what stage can infants raise their heads and gain control of their trunks before walking due to which directional pattern of development?

Correct answer: A

Rationale: The correct answer is A: Cephalocaudal. The cephalocaudal pattern of development means that growth and motor control proceed from the head downward through the body. This explains why infants can raise their heads before they can sit and gain control of their trunks before walking. Choices B, C, and D are incorrect. Anterior to posterior refers to development from the front to the back, while proximodistal refers to development from the center of the body outward. Normal growth curve charts are used to track physical growth over time and are not directly related to the directional pattern of development in infants.

4. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

5. A parent calls the hospital nursing hotline and asks, 'My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?' What should the nurse's response be to this parent?

Correct answer: B

Rationale: The correct response for the nurse to provide in this situation is to ask more questions to determine if the infant is displaying symptoms of colic. Colic is a common condition in infants that can lead to prolonged crying and fussiness. It is essential to assess for other symptoms before giving advice to the parent. Choices A, C, and D are incorrect because they do not address the possibility of colic or the need for further assessment of the infant's condition.

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