what self report pain rating scales can be used in children as young as 3 years of age
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. What self-report pain rating scales can be used in children as young as 3 years of age?

Correct answer: C

Rationale: The FACES Pain Rating Scale is suitable for children as young as 3 years of age. It uses facial expressions to depict different levels of pain, making it easy for young children to understand and use. The Poker Chip Tool is validated for children aged 4 and older who have a certain level of cognitive ability. The Visual Analog Scale is more appropriate for children aged 7 and above. The Word-Graphic Rating Scale, which uses descriptive words, is recommended for children in the age range of 4 to 17 years.

2. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?

Correct answer: C

Rationale: A diet rich in vegetables, legumes, and starches can provide sufficient amino acids, particularly when complemented with varied food sources to ensure a balanced intake of essential nutrients.

3. A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?

Correct answer: B

Rationale: Visine is not harmless when ingested, and immediate medical treatment is necessary due to the risk of toxicity. Vomiting should not be induced without medical advice, and dilution with water is not an appropriate treatment.

4. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

5. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?

Correct answer: C

Rationale: PCA pumps are designed to deliver both a continuous baseline dose and patient-activated bolus doses, which can help manage pain effectively while minimizing the risk of overdose.

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