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. An infant weighed 8 lb at birth and was 18 inches in length. What weight and length should the infant be at 5 months of age?

Correct answer: C

Rationale: By 5 months, an infant's weight should typically double from birth, and length should increase by approximately 50%.

3. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

Correct answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

4. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

5. The clinic nurse is reviewing the immunization guidelines for hepatitis B. Which are true of the guidelines for this vaccine?

Correct answer: B

Rationale: Hepatitis B vaccination should start at birth, and any child or adolescent not vaccinated should complete the series. Adolescents should receive three doses if they were not previously vaccinated.

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