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. Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

Correct answer: A

Rationale: The correct answer is A: Sitting independently. By 11 months, most infants can sit independently. This milestone usually precedes walking, which typically occurs closer to 12 months. Turning a doorknob and building a tower of four cubes involve more complex motor skills that are typically achieved later in development. Therefore, at 11 months, sitting independently is the milestone that the nurse would expect an infant to have achieved.

3. With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?

Correct answer: C

Rationale: A BMI-for-age at the 85th percentile indicates a child is at risk for being overweight, according to the National Center for Health Statistics criteria.

4. A toddler’s mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse’s response should be based on which premise?

Correct answer: B

Rationale: Radiographic examination is essential to confirm the location of the battery, as it can cause significant damage, particularly if lodged in the esophagus. Immediate surgery may be required depending on its location and the potential for causing harm.

5. The nurse is conducting discharge teaching to an adolescent with a methicillin-resistant Staphylococcus aureus (MRSA) infection. What should the nurse include in the instructions?

Correct answer: B

Rationale: Avoiding sharing of towels and washcloths, using bleach when laundering, and taking daily baths with antibacterial soap are critical to prevent the spread of MRSA. Cold water is not effective for laundering in these cases.

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