Which is the most consistent and commonly used data for ...

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Which is the most consistent and commonly used data for assessment of pain in infants?
 
  a. Self-report
  b. Behavioral
  c. Physiologic
  d. Parental report

Question 2

The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.)
 
  a. S4 heart sound
  b. S3 heart sound
  c. Grade II murmur
  d. S1 louder at the apex of the heart
  e. S2 louder than S1 in the aortic area

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Answer to Question 1

ANS: B
Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

Answer to Question 2

ANS: A, C, E
S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation. A grade II murmur is not normal; it is slightly louder than grade I and is audible in all positions. S3 is normally heard in some children. Normally, S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area.