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. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

Correct answer: C

Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.

3. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?

Correct answer: A

Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.

4. The clinic nurse is instructing parents about caring for a toddler with ascariasis (common roundworm). Which statement made by the parents indicates a need for further teaching?

Correct answer: B

Rationale: Roundworm (ascariasis) is typically transmitted through ingestion of contaminated soil, not directly from person to person. This statement indicates a misunderstanding requiring clarification.

5. Which type of family should the nurse recognize when the paternal grandmother, the parents, and two minor children live together?

Correct answer: C

Rationale: An extended family includes relatives such as grandparents, aunts, uncles, and other extended family members living together, beyond just the nuclear family unit.

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