The nurse is admitting a school-age Vietnamese client who hit a ...

[tiffannnnyyyyyy]

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.

Question 2

The nurse is conducting a nutritional assessment for a toddler client who is diagnosed with failure to thrive (FTT). Which parameters will the nurse include in the assessment process for this toddler and family?
 
  1. Height
  2. Weight
  3. Hemoglobin and hematocrit
  4. Twenty four hour food diary
  5. Maternal dietary intake during pregnancy

[cat123]

Answer to Question 1

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.

Answer to Question 2

Correct Answer: 1,2,3,4
Rationale: In order to adequately assess the toddler client's FTT, the nurse would plan to measure height and weight; obtain a hemoglobin and hematocrit; and ask the family for a twenty-four hour food diary. Information regarding maternal dietary intake during pregnancy is not information that is necessary to assess for a toddler diagnosed with FTT.