Author Question: The nurse notes that a client has a goal of serum sodium within normal limits. The nurse reviews the ... (Read 27 times)

Alainaaa8 · **on:** Jul 22, 2018

The nurse notes that a client has a goal of serum sodium within normal limits. The nurse reviews the chart expecting to note:

1. The client experiences joint pain.
2. The client is experiencing edema.
3. The client is constipated.
4. The client is experiencing wheezing respirations.

Question 2

The nurse is caring for a 2-year-old child in the postoperative period. The pain assessment tool most appropriate for assessment of pain intensity in a 2-year-old is the:

1. FLACC Behavioral Pain Assessment Scale.
2. Faces Pain Rating Scale.
3. Oucher Scale.
4. Poker Chip Tool.

bassamabas · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2
2. The client is experiencing edema.

Rationale:
Communication is crucial in the medical field. The nurse who is taking over the client's care would note the client's goals and would view the assessment to determine the reason for the nursing diagnosis and goals in order to be able to evaluate if goals have been met. Edema can be a result of a high sodium level. The nurse reviews the assessment to look for the reason the goal was set. Joint pain would be relevant for a different goal. Constipation would not be related to a high sodium level. Wheezing would be addressed by a different goal for the client.

Answer to Question 2

1. FLACC Behavioral Pain Assessment Scale.

Rationale:
The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales, and can usually be used with children 3 and older.