The nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic and denies pain
Which nursing actions are most appropriate in this situation?
1. Use the FLACC scale to determine the child's pain level.
2. Tell the child to ring the call bell if the leg starts hurting.
3. Administer pain medication now and continue on a regular basis.
4. Ask the child's parents to notify the nurse if the child complains of pain.
5. Use the NIPS scale to determine the child's pain level.
Correct Answer: 1,3,4
Rationale: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The child's stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.
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