Which pain interventions should the nurse include in the plan of ...

[lindiwe]

Which pain interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury? Select all that apply.
 
  1. Using an age-appropriate assessment scale
  2. Covering the affected skin as much as possible
  3. Providing analgesics prior to wound care
  4. Keeping the skin as clean and dry as possible
  5. Clipping hair around the wound

Question 2

While interviewing the parents of a toddler-age client, the nurse notes that the mother is pregnant. At the end of the visit, the nurse decides to give a new pamphlet to the parents about car seat usage for newborns. Which is the purpose of this action by the nurse?
 
  1. Secondary preventative health maintenance
  2. Developmental health screening
  3. Tertiary preventative health maintenance
  4. Primary preventative health maintenance

[allisonblackmore]

Answer to Question 1

1, 2, 3
Explanation:
1. Pain assessment with an age-appropriate scale is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury.
2. Covering the affected area to prevent temperature changes and air movement is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury.
3. Analgesics administration prior to wound care is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury.
4. Keeping the skin as clean and dry as possible is an appropriate intervention to decrease infection, not pain.
5. Clipping hair around the wound is an appropriate intervention to decrease infection, not pain.

Answer to Question 2

4
Explanation:
1. The secondary level of prevention is focused on diagnosis of a problem, usually medical in nature, in order to address it and make a plan of care.
2. This is education, and not a developmental screening to elicit data. The focus of the teaching is on an unborn child, so developmental level is not a current issue.
3. The tertiary level of preventative care is related to restoring a level of functioning that is below an expected level, such as in a rehabilitation situation.
4. The teaching regarding proper car seat use is an example of an activity that might decrease the opportunity for injury in a newborn; therefore, this is primary preventive health maintenance.