The nurse is caring for a two-year-old child in the postoperative period. The pain assessment tool most appropriate for assessment of pain intensity in a two-year-old is the:
1. Poker Chip Tool.
2. Oucher Scale.
3. Faces Pain Rating Scale.
4. FLACC Behavioral Pain Assessment Scale.
4
Rationale 1: The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children three and older.
Rationale 2: The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children three and older.
Rationale 3: The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children three and older.
Rationale 4: The FLACC scale is an appropriate tool for infants and young children who cannot report pain.
Global Rationale:
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The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency. The nurse would incorporate which of the following as a priority in the plan of care?
A) Protecting the client from infection B) Providing emotional support to decrease fear C) Encouraging discussion about lifestyle changes D) Identifying factors that decrease the immune function
A client is taking carbamazepine (Tegretol). What type of seizure activity does the nurse anticipate this client has experienced?
1. Tonic-clonic seizures 2. Petit mal seizures 3. Partial seizures 4. Grand mal seizures
A nurse is educating a group of nursing students about systemic veins and venules. Based on this information, what is the best response from the nursing student about why the systemic veins and venules are called "blood reservoirs"?
A) The branches of veins grow larger and larger as they near the heart. B) The total length of blood vessels in the body is about 60,000 miles. C) The normal amount of blood pumped is 4 to 6 L in 1 minute. D) They house approximately 60% of the body's blood volume at rest.
The phase of the nursing process when the nurse gathers data about the patient to establish a plan of care is the
A) Assessment B) Goals C) Interventions D) Evaluation