Ch. 36: Pain Management in Children

The experienced nurse is providing shift handoff to a graduate nurse. Which statement of pain management by the graduate nurse requires clarification by the expert nurse? "Opiates can be given to children without untoward effects." "Adults as well as children can suffer from respiratory depression if given too much morphine." "There is no more danger of respiratory depression in children than in adults." "Children should not be given morphine, because they are at risk for respiratory depression."

"Children should not be given morphine, because they are at risk for respiratory depression." RATIONALE: All the statements are true except for the one stating that children should not be given morphine because of a danger of respiratory depression. If the dosage of an opiate is based on the child's size, then there is no more danger of respiratory depression in children than in adults. Morphine is the most common pain medication for children with moderate to severe pain.

The nurse is providing family education for the administration of ibuprofen. Which response indicates a need for further teaching? "This medication is taken by mouth." "This should be given with food to avoid upsetting his stomach." "I should monitor for signs of easy bruising or bleeding gums." "This can be taken with other medications we have at home that didn't require a prescription."

"This can be taken with other medications we have at home that didn't require a prescription." RATIONALE: The nurse must emphasize that the parents should carefully read labels of over-the-counter medications they already have or will purchase. Some may contain ibuprofen or other nonsteroidal anti-inflammatory drugs, and if given in conjunction with ibuprofen may lead to overdose. The other statements are correct.

A 7-year-old child has a prescription for 10 mg/kg PO acetaminophen. The child weighs 55 lb (25 kg). The acetaminophen is supplied as 80 mg tablets. How many tablets should the nurse administer? Record your answer using a whole number.

3 RATIONALE: Desired dose = Prescribed amount (mg/kg) x weight (kg) = 10 mg/kg x 25 kg = 250 mg Dose available = 80 mg Dose to administer = Desired (mg) x Quantity (tabs) = 250mg x 1 tab = 3.125 tabs rounded to 3 Available (mg) 80mg

A 7-year-old boy tells the nurse that his head sometimes hurts after he eats ice cream. The nurse recognizes that this type of pain is: Chronic cutaneous pain Acute referred pain Chronic somatic pain Acute visceral pain

Acute referred pain RATIONALE: Acute pain means sharp pain, as is the case in this scenario. It generally occurs abruptly after an injury. The pain of a pin prink is an example. Chronic pain is pain that lasts for a prolonged period or beyond the time span anticipated for healing. Referred pain is pain that is perceived at a site distant from its point of origin. In this case, the typical ice cream "brain freeze" is a headache that results from the contact of the cold ice cream with the digestive tract.

Moderate sedation is a pain-management technique that is used with children. During moderate sedation for a preschooler, which action would be most important? Keeping the room absolutely quiet so the child can sleep Keeping the child's head in a dependent position Asking the child to periodically count from 1 to 10 Assessing vital signs frequently, because they can become depressed

Assessing vital signs frequently, because they can become depressed RATIONALE: Moderate sedation is a medically controlled state of depressed consciousness that allows the protective reflexes to be maintained. The depressed state can be caused by many medications: midazolam, ketamine, propofol, etc. Children often pass through their intended level of consciousness to a deeper level. It is imperative that the child be continuously monitored, the person administering the drugs be skillfully trained in pediatric advanced life support, and there be emergency equipment and drugs available at all times during the procedure.

A nurse is instructing the parents of a toddler on the use of an anesthetic cream in advance of an upcoming procedure the child will have. What information should the nurse mention to them? Do not cover the site of the cream application with any kind of dressing. Administer the cream about 4 hours before the procedure. Do not apply the cream until you are at the hospital, a few minutes before the procedure is to begin. Be careful not to let your son remove the dressing, as the cream can cause damage to his eyes if he rubs them.

Be careful not to let your son remove the dressing, as the cream can cause damage to his eyes if he rubs them. RATIONALE: To reduce the pain of procedures such as venipuncture, lumbar puncture, and bone marrow aspiration, a local anesthetic cream that contains 4% lidocaine can be used. The cream is applied to the skin, and the site is then covered with an occlusive dressing or plastic wrap to keep young children from wiping away or tasting the cream. The time needed for effect between different brands varies from 30 minutes to 1 hour, so it must be applied within that time frame before an expected procedure. Caution the parents not to allow their child to remove the dressing as the cream could anesthetize the gag reflex if eaten or cause eye damage if rubbed into the eyes.

The nurse is reviewing the care plan and records of a 14-year-old on the oncology unit who is receiving opioid pain medication. The client normally has a bowel movement on a daily basis, but the client is at tisk for constipation related to opioid analgesic agents. What would be the best goal for this client's risk? Client will not be constipated during the stay in the facility. Client will have a bowel movement without difficulty. Client will voice no difficulty with bowel movements. Client will have a soft, formed bowel movement daily.

Client will have a soft, formed bowel movement daily. RATIONALE: Since the client's normal bowel pattern is daily, the most measurable goal describes the characteristics of normal stools on a daily basis. The other options are not measurable, making it impossible to measure during the evaluation phase of the nursing process.

The nurse is caring for an infant who was injured in a severe automobile accident. The child experienced several fractures and is in significant pain. The child's mother questions if this will impact her child later in life. What information should be provided by the nurse? There are no studies that consider the impact of pain in infancy on the child later in life. Although the pain is severe at this time a child under the age of 2 will not be able to recall the event. Pain that is short in duration in infancy will not influence the child later. Experiences with pain even in infancy can influence an individual's response to pain later.

Experiences with pain even in infancy can influence an individual's response to pain later. RATIONALE: Repeated exposure to painful procedures and events can have long-term consequences. Memories of pain may be stored in the child's nervous system, influencing later reactions to painful stimuli.

The nurse is caring for a 12-year-old with cerebral palsy who is unable to communicate verbally. Which pain assessment tool is the most appropriate for the nurse to use when assessing pain in this client? Face, leg, activity, cry, and consolability (FLACC) descriptors Adolescent pediatric pain tool (APPT) Pain diary Numeric rating scale

Face, leg, activity, cry, and consolability (FLACC) descriptors RATIONALE: If the child has cognitive deficits, use tools for pain assessment that are appropriate for developmental level. Do not use chronologic age as a basis for pain assessment. When the child is unable cognitively to communicate pain, assessment methods used for infants may be employed, such as a FLACC scale. Use of a pain diary requires handwriting skills and use of a numeric rating scale or APPT scale requires verbal and/or cognitive skills.

The nurse is preparing a 6-year-old child for a bone marrow biopsy. The child is very anxious about going through this procedure. Which nursing diagnosis best fits this situation? Pain related to an invasive procedure Pain related to fear and anxiety of painful procedure Disturbed sleep pattern related to fear of pain Fear related to anticipation of painful procedure

Fear related to anticipation of painful procedure RATIONALE: Fear related to anticipation of painful procedure is the most appropriate nursing diagnosis for this situation because the child is anxious about the painful procedure. The child is not experiencing pain yet, nor is the child trying to sleep.

Which nursing intervention demonstrates proper use of cutaneous stimulation to relieve pain in pediatric clients? Use of a cold pack for the treatment of cellulitis on an extremity. Use of a cold pack for 20 minutes to achieve a muscle temperature of 104°F (40°C). Gently massaging a preterm infant's leg for 2 minutes prior to obtaining a blood sample from a heel stick. Use of a heat pack after abdominal surgery for a 2-week-old infant with necrotizing enterocolitis.

Gently massaging a preterm infant's leg for 2 minutes prior to obtaining a blood sample from a heel stick. RATIONALE: Gentle massage of the leg for 2 minutes prior to heel stick may decrease pain response in preterm infants. Massage and pressure relax the muscles and decrease the tension. It also increases blood flow to the area. Use of heat or cold therapy is contraindicated in infants, who are more prone to thermal injuries. Ice packs should not be used for longer than 15 minutes at a time. Heat is most effective in relieving pain from inflammation and spasm.

The pediatric nurse is mentoring a new graduate in the care of children experiencing pain. The nurse knows the teaching was effective when the new graduate makes which statement as the rationale for considering pain assessment? Pain assessment needs to be done at regular intervals. Nurses often forget to assess pain. Pain assessment is difficult to measure. It is important to keep children free of pain.

Pain assessment needs to be done at regular intervals. RATIONALE: Pain assessment is so important that it should be done at regular intervals. Nurses do not forget to assess pain, but it is important to include it with each assessment. It is not possible to keep children free of pain, but it is important to assess it regularly and help relieve the pain as much as possible.

A six-year-old child is observed sucking the thumb and baby talking while hospitalized for cellulitis. How would the nurse explain this to the parents? The child is afraid of the nurse. The child may be in pain. The child wants attention. The child is acting out.

The child may be in pain. RATIONALE: Some children of school age will regress with pain such as returning to baby talk, thumb sucking, or lying in a fetal position. This child is not seeking attention, acting out, or appearing to be fearful of the nurse.

When assessing a wound for proper anesthetic effect, which finding would indicate the wound would be ready for suturing? The nurse can visualize a darkened appearance. The nurse can visualize a blanching effect. The nurse can visualize a blue tone. The nurse can visualize fresh bleeding.

The nurse can visualize a blanching effect. RATIONALE: When assessing readiness of an anesthetic agent, the nurse should assess for a change in the skin color. This is either blanching or redness. A blue or darkened color would not indicate the effectiveness of the local anesthetic and may indicate a complication that should be assessed. If the wound requires suturing, fresh bleeding may continue to occur even though the surrounding skin is anesthetized. A local anesthetic will control pain, not bleeding.

After receiving pain medication for 7 days, the client has begun to request pain medication more frequently. What inference about this occurrence is most credible? The client is experiencing symptoms consistent with withdrawal between the medication dosing periods. The client's condition is worsening, making this analgesic regimen ineffective. The child is beginning to display signs consistent with addiction. Tolerance to the medication is beginning to take effect.

Tolerance to the medication is beginning to take effect. RATIONALE: Drug tolerance occurs when increasing doses are required to manage the pain. Physical dependence can occur after as few as 5 days of continuous use of the drug; symptoms of withdrawal begin if it is suddenly stopped. There are no signals that addiction is of concern for this client.

An adolescent is experiencing severe pain due to a sickle cell crisis. Which medication would be best for the nurse to administer? ibuprofen hydromorphone naproxen acetylsalicylic acid (aspirin)

hydromorphone RATIONALE: For managing severe or acute pain, such as postoperative pain or the pain of a sickle cell crisis, opioids (e.g., morphine, oxycodone, and hydromorphone) are frequently prescribed. NSAIDS and acetylsalicylic acid would not help severe pain.

What are some negative effects that chronic pain can have on the pediatric population? increased blood pressure, increased heart rate, and sleep disturbances increased appetite, sleep disturbances, and irritability weight loss, increased blood pressure, and increased heart rate sleep disturbances, exhaustion, irritability, mood disturbances, and depression

sleep disturbances, exhaustion, irritability, mood disturbances, and depression RATIONALE: Chronic pain is defined as pain that continues past the expected point of healing for the injured tissue. This pain has many effects as the child continues in pain. These effects may include sleep disturbances, exhaustion, irritability, mood disturbances, and depression. Heart rate, respiratory rate, and blood pressure increases are seen more with acute pain. Children in any type of pain have a decreased (not increased) appetite.

The nurse is caring for a pediatric client experiencing mild to moderate pain related to a recent bone marrow biopsy procedure. The child is receiving chemotherapy treatments for a cancer diagnosis. The child has several p.r.n. pain medication options on the medication administration record. Which medication should the nurse administer? acetaminophen morphine naproxen fentanyl

acetaminophen RATIONALE: Acetaminophen is a relatively safe medication use to treat mild to moderate pain, and it does not have the same GI or antiplatelet effects of NSAIDs (such as naproxen); therefore, it would be the best choice since this child is receiving chemotherapy treatments for cancer. Morphine and fentanyl are opioid analgesics used for moderate to severe pain.

The nurse is caring for a preterm infant who requires a heel stick to obtain a blood sample. Which action by the nurse demonstrates a lack of understanding regarding pain in infants? attempting the heel stick when the infant is asleep to minimize long-term effects of pain assessing for a drop in oxygen saturation as an indicator of pain in this infant assessing for chin quivering in this infant as it can be an indicator of pain encouraging nonnutritive sucking because this infant is likely to experience pain at a greater intensity

attempting the heel stick when the infant is asleep to minimize long-term effects of pain RATIONALE: Research suggests that preterm infants experience pain at a greater intensity than older children or even adults. The reason for this may be that the inhibitory mechanisms higher in the central nervous system have not had time to develop. In preterm and term newborns, behavioral and physiologic indicators are used for determining pain. Behavioral indicators include facial expression (such as brow contracting and chin quivering) and physiologic signs include changes in oxygen saturation levels. Repeated exposure to painful procedures and events can have long-term consequences and infants feel pain and at a greater intensity regardless if they are sleeping. Sleeping can also be a coping mechanism for the child in pain.

The nurse is caring for a 2-year-old postoperative PET client. Which consideration is the most appropriate for this child's developmental stage? understands time uses words for pain such as owie, boo-boo, or hurt uses delays to put off treatment fears bodily mutation or injury

uses words for pain such as owie, boo-boo, or hurt RATIONALE: The toddler uses simple terms to describe pain, such as owie, boo-boo, or hurt. School-aged and preschool-aged children fear bodily mutilation. Preschool-aged children delay or put off treatment, and school-aged children understand time.

The nurse is caring for a client who has been diagnosed with a tumor in the small intestine that is pressing on the liver. Which type of pain does the nurse anticipate the client will report? visceral chronic pain deep somatic neuropathic

visceral RATIONALE: Visceral pain is often produced by disease. It usually is diffuse and poorly localized and is described as a deep ache or sharp stabbing sensation that may be referred to other areas. Deep somatic pain typically involves the muscles, tendons, joints, fasciae, and bones and causes dull, aching, or cramping pain. Neuropathic pain usually results in burning, tingling, shooting, squeezing, or spasm-like pain. Chronic pain is defined as pain that continues past the expected point of healing for injured tissue.

The neonatal nurse is preparing to perform a heel prick for blood work on a 3-day-old infant. Which procedural pain management will the nurse provide the client? pacifier with oral glucose oral acetaminophen high-contrast images to look at singing a lullaby

pacifier with oral glucose RATIONALE: Oral glucose has been demonstrated to provide effective pain relief to infants undergoing painful procedures. It provides both distraction and the release of endorphins and an analgesic effect. Looking at images or singing a lullaby are not effective distractions for pain management for a 3-day-old infant. Acetaminophen is longer acting and is not necessary or effective for mild, short-term procedural pain for an infant of this age.

A 5-year-old child has been admitted to the hospital and is going to have an IV started in the procedure room. Which instructions will be most helpful for the child and the parent? Instruct the parent to help restrain the child during the procedure. Have the parent sing softly to the child during the procedure. Instruct the parent to stay in the back of the procedure room. Have the parent wait in the hospital room until the procedure is over.

Have the parent sing softly to the child during the procedure. RATIONALE: Distraction techniques aim at shifting a child's focus from pain to another activity or interest. Research has demonstrated that having parents present during painful procedures and using distraction works best to decrease the pain. It is not wise to have the parent restrain the child, as this leads to distrust between the child and parent. Having the parent stay in the back of the room or stay in another room does not provide support to the child during the painful procedure.

The nurse is planning immediate postoperative care for an infant after repair of a cleft lip. What should the plan include? Allow the infant to be as active as possible after surgery. Pain medication should be given on a routine basis. Encourage use of pacifier after surgery. Crying is good for the infant to decrease risk of pneumonia after anesthetic.

Pain medication should be given on a routine basis. RATIONALE: After any surgery on a child, the plan should include pain medication administration on a routine basis. The child's pain should be assessed regularly using the appropriate assessment tool. Providing pain medication will help the infant in the postoperative period. The infant having a cleft lip repaired should not use a pacifier for at least 10 days or upon instructions from the surgeon. Sucking is very limited immediately after surgery. If the infant is breastfed, the infant may begin to feed much sooner than a bottle-fed baby. This is because the breast nipple conforms to the mouth. If bottle fed, the infant will need to use special feeding devices. Crying is not good for the infant, because it irritates the mouth and lips and has the potential to cause bleeding as it produces tension on the suture line.

A nurse is attempting to assess the extent of an injury a 5-year-old child sustained when falling down a flight of stairs. The child is visibly upset but capable of communicating. Which pain scale would be most appropriate to use in this situation? CRIES inventory FLACC pain assessment tool Poker chip tool Pain Experience Inventory

Poker chip tool RATIONALE: The poker chip tool uses four red poker chips placed in a horizontal line in front of the child. Each chip represents a different level of pain. The technique can be used with children as young as 4 years of age, provided the child has some concept of "more or less." The Pain Experience Inventory is designed to elicit the terms a child uses to denote pain and what actions a child thinks will best alleviate pain. If possible, it should be used before the child has pain. The CRIES inventory is a 10-point scale named for five physiological and behavioral variables commonly associated with neonatal pain (Crying, Requires increased oxygen administration, Increased vital signs, Expression, Sleeplessness) and thus is not age-appropriate in this case. The FLACC (Faces, Legs, Activity, Cry Consolability) pain assessment tool is a scale by which health care providers can rate a young child's pain when a child cannot give input, such as during circumcision.

The nurse is working with the mother of a 6-year-old girl to think of an effective means of distracting the girl from a painful procedure that she will shortly undergo. To be effective, the distraction technique must have which characteristics? Requires concentration of the child Refers to some past positive experience of the child Requires interaction with another person Makes the child laugh

Requires concentration of the child RATIONALE: When helping parents choose a distraction technique such as blowing soap bubbles with their child, be certain they do not interpret "distraction" as just talking to the child or suggesting a video game to divert attention. Although these are distractions, a distraction activity must require concentration; simple distractions can allow pain to break through. The other answers listed are not necessary as a part of distraction techniques.

The nurse is caring for a 2-year-old child who has been hospitalized after being injured in an automobile accident. During the assessment the child is quiet and watchful of all the nurse's actions. When considering the level of pain being experienced by the child what inference can be made? The child is feeling too shy to communicate any pain or discomfort. The child is most likely tired. The child's nonverbal behaviors may indicate the presence of discomfort. The child is not experiencing any significant level of pain or discomfort.

The child's nonverbal behaviors may indicate the presence of discomfort. RATIONALE: Responses to pain can vary in children. A child of this age may present with vocal behaviors indicating pain. The child may be tearful or crying loudly. Being quiet can also signal pain.

The nurse is caring for a 12-year-old postoperative spinal rod placement client with scoliosis. Which factor might intensify the child's postoperative pain experience? The parents describe the client as being a difficult child. The client is 12 years old. The client had a painful experience with an appendectomy at age 10. Pain control methods were discussed with the client prior to the procedure.

The client had a painful experience with an appendectomy at age 10. RATIONALE: Negative painful past experiences can intensify a child's response to pain. Temperament has not been shown to influence the actual intensity of the pain experience, but it does seem to influence a child's expression of pain behavior. Age does not intensify the pain experience. Discussion of pain control methods can alleviate stress and therefore decrease the pain experience.

The nurse is caring for a 6-year-old sickle-cell client in an acute care setting. A high priority for this client's plan of care is pain relief. The nurse understands that untreated acute pain can lead to which physiologic effects? nausea, vomiting, migraine headaches, and developmental regression impaired mobility, anorexia, anxiety, sleep disturbances, and developmental regression constipation, nausea, and vomiting sleep disturbances, nocturnal enuresis, and impaired mobility

impaired mobility, anorexia, anxiety, sleep disturbances, and developmental regression RATIONALE: Unrelieved acute pain can lead to impaired mobility; anorexia, causing poor nutritional intake; delayed wound healing; anxiety and irritability; somatic symptoms; sleep disturbances; avoidance; developmental regression; and increased parental distress. Constipation, nausea, vomiting, nocturnal enuresis, and migraine headaches are not effects of acute pain.

The nurse is caring for a client receiving opioid medication for the treatment of postoperative pain. What are common side effects that the nurse should observe for? hypotension, nausea and vomiting, and diarrhea constipation, hypertension, and disorientation respiratory depression, constipation, and pruritis respiratory depression, diarrhea, and hypotension

respiratory depression, constipation, and pruritis RATIONALE: Nausea and vomiting, pruritis, sedation, respiratory sedation, constipation, and urinary retention are common side effects of opioid medications. Hypotension, hypertension, diarrhea, and disorientation are not common side effects of opioid medication.

An adolescent is brought to the emergency department after being injured during a baseball game. The adolescent reports significant ankle pain, rating it as 8 on a scale of 0 to 10. Based on the nurse's understanding of pain impulses, the nurse would identify the adolescent's pain as reflecting which type of pain? cutaneous referred somatic visceral

somatic RATIONALE: Somatic pain is pain that originates from deep body structures such as muscles or bones. Referred pain is pain that is perceived at a site distant from its point of origin. Visceral pain involves sensations that arise from internal organs such as the intestines. Cutaneous pain is pain that arises from superficial structures such as the skin and mucous membranes.

When providing education to a parent regarding pain management for a toddler with otitis media, which statement by the parent indicates further teaching is needed? "I should give my toddler one baby aspirin." "Ibuprofen can be purchased over the counter to use if my toddler needs it." "Use of infant acetaminophen is good for my toddler." "I do not have to give my toddler pain medication unless it is needed."

"I should give my toddler one baby aspirin." RATIONALE: Children, including toddlers, should not use acetylsalicylic acid for routine pain management or to treat fever because of the increased risk of Reye syndrome. The use of the other options is appropriate and all statements indicate an understanding of pain management for this child.

The nurse is caring for a client who is in a sickle cell crisis. The child is hospitalized for pain management during the crisis. The parents tell the nurse that they do not think their child needs any pain medication because the child is sleeping a lot. How should the nurse respond? "The pain medication is prescribed on a routine basis to keep the pain under control, so I have to give it as prescribed." "I agree. Since your child is sleeping the pain must not be too severe. I will hold his pain medication." "We need to wait for your child to express the pain level to us before providing medication." "I understand why you think your child is not in pain; sleep is often a way for children to cope with pain."

"I understand why you think your child is not in pain; sleep is often a way for children to cope with pain." RATIONALE: Sleep or play may be a coping strategy for the child in pain, and sleep may reflect exhaustion of the child who is coping with pain; therefore, the nurse and parents should not assume the child is pain-free. There is no need to wait for the child to express the pain level to the nurse. Often, children deny pain or may assume that others know how they are feeling and thus will not verbalize their pain. Telling the parents that the medication must be given as prescribed does not address the parents' concern.

The nurse is caring for a client who is in a sickle cell crisis. The child is hospitalized for pain management during the crisis. The parents tell the nurse that they do not think their child needs any pain medication because the child is sleeping a lot. How should the nurse respond? "The pain medication is prescribed on a routine basis to keep the pain under control, so I have to give it as prescribed." "We need to wait for your child to express the pain level to us before providing medication." "I agree. Since your child is sleeping the pain must not be too severe. I will hold his pain medication." "I understand why you think your child is not in pain; sleep is often a way for children to cope with pain."

"I understand why you think your child is not in pain; sleep is often a way for children to cope with pain." RATIONALE: Sleep or play may be a coping strategy for the child in pain, and sleep may reflect exhaustion of the child who is coping with pain; therefore, the nurse and parents should not assume the child is pain-free. There is no need to wait for the child to express the pain level to the nurse. Often, children deny pain or may assume that others know how they are feeling and thus will not verbalize their pain. Telling the parents that the medication must be given as prescribed does not address the parents' concern.

The nurse is caring for a child who is experiencing postoperative pain after having undergone surgery several hours ago. The child's parent reports having taken meperidine for postoperative pain and wonders if that medication would be of benefit to the child. What response by the nurse is indicated? "Meperidine often causes severe nausea, vomiting and diarrhea in children and its use should be limited." "Since this medication worked for you it may indeed be of benefit to your child." "Meperidine is associated with toxicity issues in children and is usually avoided." "I can certainly contact the surgeon about prescribing this medication for your child."

"Meperidine is associated with toxicity issues in children and is usually avoided." RATIONALE: Meperidine, an opioid agonist, is not recommended as a first-choice agent for pain relief in children due to its toxicity on the central nervous system

A 4-year-old child is being prepared for a colonoscopy with intravenous fentanyl and midazolam. What statement by the parents demonstrates understanding of the nurse's teaching about these medications? "Our child will feel all the pain but not have any memories of the procedure." "Our child will be asleep through the procedure and will not feel pain." "Our child will be sleepy but able to respond and will feel minimal pain." "Our child will be alert but will not experience pain during the procedure."

"Our child will be sleepy but able to respond and will feel minimal pain." RATIONALE: Conscious sedation with fentanyl provides pain relief and midazolam provides sedation. The memories of the procedure are depressed by the conscious sedation. The child is anticipated to be sleepy but able to respond and to feel minimal pain with the procedure. The child will not be asleep nor alert during the procedure. The pain will be minimized by these medications.

The nurse is preparing a 6-year-old for a venipuncture. The boy appears anxious and is crying. How can the nurse foster feelings of control to help minimize his anxiety about the procedure? "See how fast you can make this pinwheel whirl." "Mrs. Jones, why don't you have him sit on your lap?" "Pick your favorite Band-Aid and show me which arm to use." "What questions do you have about what I am doing?"

"Pick your favorite Band-Aid and show me which arm to use." RATIONALE: Allowing the child options related to the style of the Band-Aid and the extremity to use gives the child some control over the happenings. Offering a pinwheel is a distraction technique. Encouraging the parent to hold the child during the procedure promotes feelings of security. Encouraging the child or parents to ask questions facilitates communication.

The mother of a child who just had abdominal surgery holds his hand and smooths his hair. When the nurse appears to administer a scheduled analgesic, the mother says she believes the child has been in pain the last hour or more. The nurse's best response is: "He looks comfortable to me and was sleeping each time I checked. The medication given earlier seems adequate." "This is the medication he gets every 4 to 6 hours. It will control his pain for that period of time." "Please tell me and all of the nurses when you believe he is in pain." "His vital signs are stable, telling me he must be comfortable." "We will check every 4 hours to see if he needs the pain medicine."

"Please tell me and all of the nurses when you believe he is in pain." RATIONALE: Having the mother share her assessments is very helpful. She knows the child the best. The statements about the medication and checking every 4 hours may be true but do not acknowledge the mother and the importance of her input. Looking comfortable (stillness) and even sleeping can be a coping strategy used by the child. Stable vital signs can be misleading. (Continually elevated signs can be interpreted as stable.) Many events can raise vital signs, including anxiety or happy excitement. Physiologic signs should be interpreted with care and combined with behavioral signs of pain.

An adolescent has been injured while playing sports. The adolescent describes only minimal pain but the nurse observes clenched fists, rapid breathing and increased muscle tension. Which approach would be best to offer this adolescent pain medication? "Pain medication is available for you. Do you want a dose at this time?" "Sports injuries can be very painful. Reducing the pain can help in the healing process." "Here is a dose of pain medication so you can be better relaxed while your injury is treated." "When you feel you would like a dose of pain medication, I will administer it."

"Sports injuries can be very painful. Reducing the pain can help in the healing process." RATIONALE: Adolescents have problems with accepting pain because of body image concerns and fear of losing control. They fear their behavior will make them look juvenile and thus try to remain stoic and not exhibit emotion. The nurse should address these concerns by being very matter-of-fact and truthful. The nurse can validate the adolescent's pain by stating the injury will cause pain. Explaining that reduction in pain can help in healing is a positive way to offer the pain medication and not make the adolescent appear to lose control. Telling the adolescent pain medication is available or that the adolescent should ask for medication can prolong the pain as the adolescent may be embarrassed to ask because of not wanting to risk being seen as weak or childish. Pain medication should be administered for pain, not as a relaxing agent to be used for treatment.

The nurse is caring for a 9-year-old boy with episodes of chronic pain. The nurse is educating the parents how to help the child manage pain nonpharmacologically. Which statement indicates a need for further teaching? "We need to identify the ways in which he shows pain." "We should perform the techniques along with him." "We should select a method that he likes the best." "We should start the method after he feels pain."

"We should start the method after he feels pain." RATIONALE: The parents must understand that they should begin the technique or method chosen before the child experiences pain or when he first indicates he is anxious about or beginning to experience pain. The other statements are accurate.

What scenario demonstrates the nurse's knowledge when using guided imagery to relieve pain in pediatric clients? Leading a 6-year-old client in a fairy princess setting where the client is the princess and the nurse is the queen. After achieving a relaxed state, begin by guiding the 3-year-old client to imagine a fun birthday party. Leading a 4-year-old client to imagine being an airplane pilot and flying across the sky. After achieving a relaxed state, begin by encouraging the 13-year-old client to imagine walking down a sandy beach and collecting seashells, a favorite activity.

After achieving a relaxed state, begin by encouraging the 13-year-old client to imagine walking down a sandy beach and collecting seashells, a favorite activity. RATIONALE: Imagery begins with achieving a relaxed state. Then, the nurse guides the child to choose a favorite place. Imagery involves the use of imagination to create a mental picture. This image is positive and pleasurable. The child associates the image with colors, sounds, smells, or feelings. When using guided imagery, the nurse should not lead the child but encourage the child to pick a mental image which will mean the most to the client. The nurse lets the child become immersed in the personal image and take command of the experience. Guided imagery is not appropriate for preschool-age children and toddlers.

The nurse is caring for a burn client with orders for oral ibuprofen and morphine PRN to control pain. Which nursing interaction is the most beneficial for the nurse to implement for pain management? Give medication when the client asks for it. Give only the ibuprofen until the client reports higher pain levels. Give morphine as little as possible to prevent unwanted side effects. Alternate these medications around the clock to diminish peaks and valleys in pain control.

Alternate these medications around the clock to diminish peaks and valleys in pain control. RATIONALE: Pain is best managed by a proactive, preemptive approach. Anticipating and treating pain is much more effective and humane than trying to manage pain once it is present. PRN administration of pain medication tends to propagate a pain cycle with peaks (side effects like sedation) and troughs (pain) of drug action. If pain is present or anticipated for most of the day, medications must be scheduled and administered around the clock (ATC), with additional doses of analgesics available for prompt relief of breakthrough pain.

The nurse is caring for children on a postoperative unit. Which nursing action promotes the most efficient pain control? Assess the child's pain on a scale of 0 to 10, with 10 being the worst. Anticipate when pain will occur and plan interventions to prevent it. Instruct parents to notify the nurse if the child's pain worsens. Avoid opioids as these may cause dependency and respiratory depression.

Anticipate when pain will occur and plan interventions to prevent it. RATIONALE: The mark of efficient pain control is to anticipate when pain will occur and plan interventions to prevent it rather than let it occur and then relieve it. Three common reasons why nurses and other pediatric providers may not provide adequate pain relief to children include a belief that infants and young children do not experience pain, a fear children will become addicted to pain relief medications, and a fear of causing respiratory depression from analgesics. Infants and young children do experience pain, and there is little chance that children receiving opioids during a short hospital stay will become opioid dependent or that opiates cause greater respiratory depression in children than in adults (Fanning, Stucke, Christensen, et al., 2012). It is helpful to have parents notify the nurse if the child's pain worsens, as well as to assess pain using a standardized tool. However, it is better to anticipate pain and prevent it than to just assess and relieve it.

The nurse plans to apply a cream with lidocaine and prilocaine to decrease the pain of an injection. What would be the best technique? Wipe it off at least 15 minutes before the procedure. Apply it immediately prior to the painful procedure. Apply it at least 1 hour before the procedure. Do not cover it after application to prevent it from discoloring.

Apply it at least 1 hour before the procedure. RATIONALE: A topical anesthetic cream containing lidocaine and prilocaine must be applied at least 1 hour prior to a superficial procedure (injections, IV starts) to be effective. It needs to be applied at least 2 to 3 hours prior to a deep procedure such as a bone marrow aspiration. The drug should be applied in a thick layer over the area. It is not rubbed into the skin. It should be covered after application with a transparent dressing. This allows for maximum absorption and to prevent the child from tasting it (which could anesthetize the gag reflex). The drug is wiped when the skin is prepped for the procedure. Lidocaine and prilocaine cream is effective in reducing pain from procedures such an IM injection up to 24 hours after the injection.

Parents are to bring their kindergarten child to the outpatient department for a venous blood sample. They have EMLA cream to apply at home prior to the procedure and have been shown two areas on the child's arms where they should place the cream. Transportation time is 15 minutes. Their appointment is for 2:45 p.m. At what time should the parents apply the cream and occlusive dressings to both arms? Right before leaving home for the clinic The parents should not apply EMLA cream due to their child's age. At 11:45 a.m. Between 1:15 p.m. and 1:45 p.m.

Between 1:15 p.m. and 1:45 p.m. RATIONALE: The EMLA cream needs to be in place 60 to 90 minutes prior to the procedure in order to attain local analgesia. Applying it at 11:45 a.m. (3 hours prior to the procedure) is necessary for deeper analgesia needed for such things as a lumbar puncture. Right before leaving their home (approximately 20 minutes before the procedure) is effective when lidocaine is used since it needs to be in place 20 to 30 minutes before a procedure. EMLA cream is approved for use in children ages 37 weeks and older.

The nurse is caring for a 12-year-old in sickle cell crisis. The nurse determines that the child is very tense and might benefit from relaxation techniques. Which is the best approach for the nurse to take when implementing this pain reduction technique? Allow the television to remain on during this intervention to provide distraction for the client. Ask parents and visitors to leave the room during this intervention. Close the door to the client's room, dim the lights, and close the curtains before beginning. Begin the intervention by having the child breathe in and out quickly 10 times.

Close the door to the client's room, dim the lights, and close the curtains before beginning. RATIONALE: Dimming the lights and closing the door to sounds, bright light, and distractions in the hall are good ways to begin a relaxation exercise. The television should be off during this technique so it will not be a distraction. Parents do not need to leave the room as this may cause increased anxiety for the child. Deep and slow breathing are relaxation techniques, not quick breathing.

The nurse is caring for a 7-year-old postoperative child who is reporting an 8 out of 10 on a pain intensity scale. The child's parent is requesting pain medication. The child received ibuprofen 3 hours ago. What is the correct nursing action? Explain to the parent the child cannot receive another dose of ibuprofen for 3 hours. Turn on the television in hopes of distracting the child. Contact the health care provider and request an opioid pain medication. Apologize to the parent and tell the parent there is nothing the nurse can do at the moment.

Contact the health care provider and request an opioid pain medication. RATIONALE: The nurse must advocate for the child. Advocacy may involve convincing a parent that opioids are appropriate for the situation or consulting with the prescriber regarding an ineffective medication regimen. Explaining to the parent that the child cannot receive any more pain medication is ineffective and does not advocate for the child in pain. Turning on the television is not a bad idea. However, it is not the priority. It is not appropriate to apologize. The nurse can do something. Contacting the health care provider to request more medication is in the nurse's power.

The nurse is assisting with the administration of the child's initial dose of parenteral opioids. Which action should the nurse take first? Ensure naloxone is readily available. Assess the status of bowel sounds. Assess for any adverse reaction. Premedicate with acetaminophen.

Ensure naloxone is readily available. RATIONALE: When administering parenteral or epidural opioids, the nurse should always have naloxone readily available in order to reverse the effects of opioids, should respiratory distress occur. Premedication with acetaminophen is not required with opioids. After administration, the nurse should continually assess for an adverse reaction. The nurse should assess bowel sounds for decreased peristalsis after administration.

A child with Down syndrome has had surgery and experiences periodic pain. The child is 13 years old but functions much like an 8-year-old. Which pain scales may be appropriate for pain assessment? Select all that apply. FACES pain rating scale Numeric pain scale Poker chip tool Adolescent Pediatric Pain Tool Word-graphic rating scale

FACES pain rating scale Poker chip tool RATIONALE: The poker chip tool has been successfully used for those 4 years of age and older. The child stacks pieces of hurt. This is concrete and would be a potential choice for use with this girl. The FACES scale can be used in children as young as 3 years. The faces are generic line drawings indicating increasing degrees of distress. The child points to the one indicating how he or she feels. This could be effective with the girl who functions as an 8-year-old. The other scales are not likely to work as well for rating this child's pain. The Adolescent Pediatric Pain Tool is useful with children ages 8 years to age 17 years. The hurt is colored, a scale rates severity, and a word list is used to describe pain. This is most likely too complex for the child with Down syndrome. The same is true for the word-graphic or numeric scale. Children between 4 years and 17 years have used it. The child is asked to indicate the level of pain on the scale following an explanation of the descriptors. This activity may not hold the attention of the child with Down syndrome and may be too wordy for adequate comprehension. Often children regress to an earlier developmental level when stressed by illness, and a simpler scale is more effective. When possible, teaching the child to use the scale prior to a painful experience aids in getting reliable feedback.

A nurse is caring for a 4-year-old child who is exhibiting extreme anxiety and behavioral upset prior to receiving stitches for a deep chin laceration. Which nursing intervention is a priority? Serving as an advocate for the family to ensure appropriate pharmacologic agents are chosen. Ensuring the lighting is adequate for the procedure but not so bright to cause discomfort. Conducting a baseline physical assessment. Ensuring that emergency equipment is readily available.

Serving as an advocate for the family to ensure appropriate pharmacologic agents are chosen. RATIONALE: When a child is manifesting extreme anxiety and behavioral upset, the priority nursing intervention is to serve as an advocate for the family and ensure that the appropriate pharmacologic agents are chosen to alleviate the child's distress. Ensuring emergency equipment is readily available and lighting is adequate for the procedure is also part of the nursing function, but secondary interventions. Conducting a baseline physical assessment is important but would likely be difficult if the child was crying inconsolably or was extremely anxious.

A parent expresses concern to the nurse that her 18-month-old child might have an ear infection. Which symptom would alert the nurse that this is a possibility? The child expresses "ouchie" in the ear. The child is crying nonstop. The child has a temperature of 100°F (38°C). The child is pulling on the ear.

The child is pulling on the ear. RATIONALE: Pulling on the ears is a typical symptom of an ear infection in a preschool child. Nonstop crying is not necessarily related to the ear, nor is an elevated temperature. An 18-month-old would not be able to express having an "ouchie" in his ear.

The nurse teaches a preschooler to use a FACES pain rating scale prior to surgery. At that time, the preschooler points to the smiling face. Following surgery when the nurse suspects the child has pain, the preschooler points again to the smiling face. How would the nurse interpret this response? The child is using the scale to predict what they would like, not what the child has. The nurse must be interpreting the child's degree of pain falsely. The child does not have pain. The child has difficulty focusing on the right side of the scale.

The child is using the scale to predict what they would like, not what the child has. RATIONALE: Preschoolers use "magical thinking," or believe that what they wish will come true. They may use pain scales, therefore, to "wish" for a smiling face, rather than for rating their pain. Preschoolers also may not report pain, thinking it is something to be expected. If the child does not report pain then the nurse should also assess the child's features: Is the child grimacing, crying, or being totally still? The nurse can also ask the parent if this is how the parent would describe the child when in pain. Pain is subjective so the nurse would not be reporting the pain falsely.

The nurse is caring for a term neonate suffering from meconium aspiration in the nursery. The nurse reviews orders for a peripherally inserted central catheter (PICC) line placement and intubation. Which statement demonstrates the nurse's knowledge of painful procedures as related to a neonate? The newborn will not remember pain and does not need analgesia for painful procedures. The newborn's pain pathway components are developed enough at birth to experience pain. Newborns are rarely subjected to painful procedures without anesthesia. The newborn does not have fully developed pain receptors, and therefore needs little or no pain medication.

The newborn's pain pathway components are developed enough at birth to experience pain. RATIONALE: Neuroanatomical and neuroendocrine components of the pain pathway are sufficiently developed in the neonate to allow the transmission and perception of pain. While infants may not remember painful experiences as distinct actual events, the functional structures for long-term memory—specifically the integrity of the limbic system and diencephalon—are well developed in newborns. These early painful experiences may be stored as procedural memory, not accessible to conscious recall. Ample evidence indicates that both term and preterm neonates have the capacity to experience and remember pain much like older children and adults do. Newborns should receive analgesia for painful procedures.

The nurse is providing postsurgical care for a 5-year-old. The nurse knows to avoid which question when assessing the child's pain level? Would you point to the spot where your pain is? Would you point to the cartoon face that best describes your pain? Would you please show me which photograph and number best describes your hurt? Would you say that the pain you are feeling is sharp or dull?

Would you say that the pain you are feeling is sharp or dull? RATIONALE: A preschooler may have difficulty distinguishing between the types of pain such as if the pain is sharp or dull. It also limits the information being obtained by the nurse. They can, however, tell someone where it hurts and can use various tools such as the FACES scale (cartoon faces) or the OUCHER scale (photograph and corresponding numbers) to rate their pain.

A 10-year-old child is scheduled for open reduction and internal fixation of the tibia following a skateboard accident. The nurse anticipates which pain medication and administration method will best provide postsurgical pain relief for this child immediately after surgery? fentanyl given as an intramuscular injection nonsteroidal anti-inflammatory drugs (NSAIDs) given orally acetylsalicylic acid (aspirin) given orally morphine given as an intravenous injection

morphine given as an intravenous injection RATIONALE: For managing severe or acute pain, such as postoperative pain, opioids like morphine or fentanyl are preferred. Immediately after surgery, the intravenous route is preferable to the oral route because the child may not be able to tolerate oral medications at that time and intravenous medications begin to work much faster than oral medications. NSAIDs, such as ibuprofen or naproxen, are excellent for reducing pain because they reduce inflammation and pain; however, the child most likely will not be able to take an oral medication immediately following surgery. NSAIDs could be given intravenously as prescribed during the immediate postoperative period. Intramuscular injections should be avoided in children because the number of suitable injection sites in children is limited, injections are associated with pain on administration, and many children are afraid of injections. As a rule, other routes for administration of pain medication are used whenever possible.

The nurse is preparing to use the FLACC behavioral scale to assess the pain level of a child. For which child will the use of this scale be the most appropriate? 4-year-old child who just had stitches placed 10-year-old child with a broken femur in traction 7-year-old child who is getting ready to undergo a dressing change postoperative 6-year-old child who is unable to accurately report pain level

postoperative 6-year-old child who is unable to accurately report pain level RATIONALE: The FLACC behavioral scale is a behavioral assessment tool that is useful in assessing a child's pain when the child is unable to accurately report his or her level of pain or discomfort and is reliable for children from age 2 months to 7 years. A 7-year-old child who is getting ready to undergo a dressing change and a 4-year-old child who just had stitches placed would be able to report pain and could use the Faces, Oucher, poker chip, or visual analog scales. A 10-year-old with a broken femur in traction would be able to self-report pain using the numeric scale. In alert children verbally able to report pain, self-report is the primary source for the measurement of pain.