The nurse is caring for a toddler who fell and is having x-rays to determine if there is a fracture. The child is in the waiting room playing happily with toys and picture books
The nurse determines that the child is experiencing pain because of which of the following? 1. The child will not use the affected arm.
2. The mother tells the nurse the child is in pain.
3. The child is playing quietly.
4. The child is ignoring other children.
1
Rationale: Very often, the only sign of pain that the nurse will see is the immobilization of the affected area of pain by the client. This can be particularly true of small children if the pain is not severe. The mother cannot tell the nurse the level of the child's pain. Toddlers might or might not play quietly, depending on the toy. Toddlers usually ignore other children and engage in parallel play.
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