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
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Nursing Elites

ATI RN

ATI Nursing Care of Children

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?

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. The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurse's best response?

Correct answer: B

Rationale: Comforting and cuddling a 2-month-old baby when they cry helps build trust and security. At this age, responding to cries does not lead to spoiling, but rather supports healthy emotional development.

3. The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

Correct answer: A

Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.

4. The nurse is preparing to admit a 6-year-old child with celiac disease. What clinical manifestations should the nurse expect to observe?

Correct answer: B

Rationale: Celiac disease often presents with steatorrhea, malnutrition, and foul-smelling stools due to the malabsorption of nutrients. Therefore, all the manifestations listed (steatorrhea, malnutrition, foul-smelling stools) are expected in a child with celiac disease. Polycythemia is not associated with celiac disease, making choice B the correct answer.

5. What is the most effective way to prevent sudden infant death syndrome (SIDS)?

Correct answer: B

Rationale: The correct answer is to place the baby on their back to sleep. This position is the most effective way to prevent sudden infant death syndrome (SIDS) according to research and recommendations from healthcare providers. Choice A, using a firm mattress, is important for infant safety but not as directly related to preventing SIDS. Keeping the room warm, as mentioned in choice C, is not recommended as it may increase the risk of SIDS. While breastfeeding has many benefits, choice D, breastfeeding exclusively is not the most effective method for preventing SIDS.

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