Nursing Elites

1. The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?

• A. Poker chip tool
• B. Oucher Scale
• C. Faces Pain Rating Scale
• D. FLACC Behavioral Pain Assessment Scale

Correct answer: D

Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.

2. What is the most consistent and commonly used indicator of pain in infants?

• A. Increased respirations
• B. Increased heart rate
• C. Thrashing of arms and legs
• D. Facial expression of discomfort

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

3. Which parental statement indicates correct understanding of information presented regarding the prevention of iron deficiency anemia in infants?

• A. "We will add green leafy vegetables to our child’s low-iron formula."
• B. "We will discontinue the use of vitamin C supplements by 6 months of age."
• C. "We will begin an iron-fortified infant cereal at 4 to 6 months of age."
• D. "We will introduce cow’s milk by 6 months of age."

Correct answer: C

Rationale: The correct answer is C. Introducing iron-fortified cereal between 4 to 6 months of age is a recommended practice to prevent iron deficiency anemia in infants. Iron-fortified infant cereals are a good source of iron for infants. Choices A and B are incorrect because adding green leafy vegetables to low-iron formula and discontinuing vitamin C supplements do not directly address the prevention of iron deficiency anemia. Choice D is incorrect because cow's milk should be avoided before 12 months of age as it is low in iron and can lead to intestinal blood loss, increasing the risk of iron deficiency anemia.

4. A four-year-old child has a history of repeated otitis media despite antibiotic treatment. Which treatment measure should the nurse discuss with the parents?

• A. Antibiotic treatment
• B. Adenoidectomy
• C. The insertion of tympanostomy (pressure equalizing) tubes
• D. Tonsillectomy

Correct answer: C

Rationale: The correct answer is C: The insertion of tympanostomy (pressure equalizing) tubes. This treatment measure is appropriate for a child with recurrent otitis media as it helps drain fluid from the middle ear and prevent further infections. Adenoidectomy (choice B) involves the removal of the adenoids, which may not directly address the ear infections. Antibiotic treatment (choice A) has already been ineffective in this case, so alternative measures are necessary. Tonsillectomy (choice D) is not typically indicated for otitis media unless there are specific reasons such as enlarged tonsils contributing to the condition.

5. A nurse is carrying on a conversation with a 7-year-old child during an office visit. Which is an example of the level of language development the nurse should expect in this child?

• A. Fascination with bathroom language
• B. Difficulty understanding the concept of 'half past' in reference to time
• C. Ability to carry on an adult conversation
• D. Inability to speak in full sentences

Correct answer: B

Rationale: The correct answer is B. Understanding time concepts like 'half past' can be challenging for a 7-year-old, indicating the level of language development. Choice A is incorrect as fascination with bathroom language is common in this age group but not necessarily indicative of language development. Choice C is incorrect as a 7-year-old typically cannot carry on an adult conversation due to cognitive and experiential limitations. Choice D is incorrect as by the age of 7, children should be able to speak in full sentences.

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