Author Question: The nurse is planning care for a school-age patient experiencing undiagnosed limb pain. Which ... (Read 72 times)

waynest · **on:** Jun 27, 2018

The nurse is planning care for a school-age patient experiencing undiagnosed limb pain. Which nursing diagnoses regarding pain should the nurse consider when designing this patient's plan of care? (Select all that apply.)

A) Pain related to an invasive procedure
B) Disturbed sleep pattern related to chronic pain
C) Fear related to anticipation of painful procedure
D) Anxiety related to dressing changes that cause pain
E) Health-seeking behaviors related to the cause of pain

Question 2

A school-age child is prescribed to receive 1,500 ml + 20 ml/kg for each additional kilogram over 20 kg of intravenous fluid over the next 24 hours. The child weighs 55 lb.

How much intravenous fluid should the nurse provide the patient for an 8-hour shift? (Enter numeric value only. Round to the nearest whole number if applicable.)

gabrielle_lawrence · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

A, B, C
Feedback:
Nursing diagnoses for children with pain focus not only on the pain but also on the stress, fear, or anxiety that pain produces. Nursing diagnoses appropriate for the child experiencing undiagnosed limb pain include pain related to an invasive procedure, disturbed sleep pattern related to chronic pain, and fear related to anticipation of painful procedure. It is unknown if the child has a dressing on the limb. The child is demonstrating health-seeking behaviors related to the cause of the pain.

Answer to Question 2

533 ml
Feedback:
The nurse needs to first determine the patient's weight in kilograms by dividing 55 lb by 2.2 or 55 / 2.2 = 25 kg. Then the nurse needs to determine how many kilograms of weight the child is over 20 or 25 kg (current weight) 20 = 5 kg. Because the child is to receive 20 ml additional fluid for every kilogram of body weight over 20 kg, the nurse should then multiply 5 kg 20 = 100 ml. Then the nurse should set up the equation of 1,500 ml + 100 ml = 1,600 ml. This is the total volume of fluid that the child is to receive in 24 hours. To determine the amount to provide during an 8-hour shift, the nurse should divide this total by 3 or 1,600 / 3 = 533.33 ml. When rounded to the nearest whole number, the nurse will provide 533 ml of fluid over 8 hours.