Comfort Module 3
A nurse is reviewing the medical record for a school-age client prior to a scheduled health maintenance visit. Which data from the record indicates that the client is overweight? A) Body mass index (BMI) >85th percentile B) BMI >95th percentile C) 25% increase in weight in a 6-month period D) 35% increase in weight in a 6-month period
Answer: A A child with a BMI greater than the 85th percentile is considered overweight. A child with a BMI greater than the 95th percentile is considered obese. Percentage of weight gain in a 6-month period (regardless of baseline) does not determine whether a client is overweight or obese.
The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover. The nurse anticipates that the child might ask the nurse if he is dying. What would be most appropriate for the nurse to do? A) Suggest a meeting with the healthcare team and the parents. B) If the child asks about death, offer to bring in the child life therapist to help explain the situation. C) Tell the child he is dying if the child asks and offer to stay with him. D) Prepare to ignore the child's question if the child asks it and change the subject.
Answer: A Offering to set up a meeting with the healthcare team to discuss the parents' fears and concerns about telling their child the truth is the best action by the nurse. Telling the child he is dying would be going against the parents' wishes. Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate, and the nurse should not simply pass the issue off to a therapist.
The nurse is caring for a pediatric client with a surgical wound. The wound is red with purulent drainage and is causing discomfort for the client. Which diagnostic test will determine if the discomfort of the wound is caused by an infection? A) White blood cell count B) Hematocrit measurement C) Urine analysis D) X-rays of the site
Answer: A There are a few tests that can help the medical team determine the source of the client's discomfort. In this case, a white blood cell count will determine if the discomfort is being caused by an infection. An x-ray is useful for determining the existence of physical injuries, not the presence of infection. Urine analysis may indicate illness or malnutrition, whereas hematocrit measurement may identify iron deficiency anemia.
An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. Which action by the nurse is the most appropriate? A) Allow the toddler to sit on the parent's lap and begin the assessment. B) Allow the toddler to stand on the floor until the crying stops. C) Ask another nurse in the office to hold the toddler because the parent is not able to control the toddler's behavior. D) Instruct the parent to hold the toddler down tightly to complete the examination.
Answer: A Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure. Allowing the toddler to stand on the floor or holding the toddler down tightly are inappropriate. A nurse can assist if the parent is unable to hold the child during the vaccinations to prevent injury from movement.
The nurse is preparing to assess a 1-year-old client for signs of discomfort. When conducting the assessment, which action by the nurse is the most appropriate? A) Asking the client to rate the pain on a scale of 0-10 during the assessment process B) Asking the parent to hold the client in the lap during the assessment process C) Reading a book to the client during the assessment process D) Recommending that the parent leave the room during the assessment process
Answer: B Children may be fearful of physical assessment. To promote comfort, allow the child to sit on the parent's or guardian's lap during the assessment process, rather than asking the parent to leave the room. A numeric pain scale is not appropriate until the client is older; a faces pain scale would be better. Reading a book during the assessment process is not age appropriate.
Which of the following triggers pain? A) The central nervous system B) The peripheral nervous system C) The musculoskeletal system D) The cardiovascular system
Answer: B Pain is triggered by the peripheral nervous system, which lies outside the brain and spinal cord of the central nervous system and does not involve the musculoskeletal or cardiovascular systems.
4) A toddler being prepared for a lumbar puncture begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate for the client at this time? A) Knowledge Deficient of the procedure B) Anxiety related to anticipated painful procedure C) Fear related to the unfamiliar environment D) Ineffective Coping related to an invasive procedure
Answer: B The child associates the treatment room with a painful procedure, and the reaction to entering the treatment room is based on anticipation of repeat discomfort. The child's behavior is appropriate for coping in a child of this age. This child is not old enough to understand the need for a lumbar puncture. The child's fear is related not to the unfamiliar environment but to the anticipated pain associated with the treatment room from having undergone painful procedures there.
The nurse is preparing to examine a toddler's ear canals with an otoscope. Which actions by the nurse are appropriate? Select all that apply. A) Having the child sit on the examination table B) Having the child play with the equipment C) Having the child sit on the parent's lap D) Telling the child the examination will not hurt E) Asking the child to tilt the head
Answer: B, C The best way to get a child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, as well as to have the child sit on the parent's lap. Asking the child to tilt the head does not encourage cooperation. Most children of this age need to see for themselves that a procedure will not hurt; simply telling the child that the procedure won't be painful is not effective.
A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply. A) "Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart." B) "Use standard precautions during the history and physical examination process." C) "Perform invasive procedures like pharyngeal and otic exams at the end of the assessment." D) "Use age-appropriate terminology for explaining procedures and actions." E) "Use the assessment process to teach about exam procedures and findings."
Answer: B, D, E Following standard precautions, employing age-appropriate terminology, and using the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducting a cardiovascular assessment during sleep is appropriate for some pediatric clients, but it would be considered an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for pediatric clients but not necessary for adult clients.
Which client is most likely to reject attempts at comfort? A) An infant crying B) A school-age child with abdominal pain who is anxious about a procedure C) An adolescent with a sleep disorder who doesn't want his parents to be near him D) An older adult with end-stage renal disease
Answer: C Adolescents may respond to treatment and comfort better if you interact with them as adults rather than as children. Some adolescents may reject any offer of comfort, and an adolescent with a sleep disorder who has displayed antagonism toward his parents' presence is probably irritable from his condition and may immediately reject attempts at comfort, at least at first. An infant crying is verbalizing the need for comfort. A school-age child anxious about a medical procedure craves reassurance. An older adult with a terminal illness likely will welcome comfort measures even if she has accepted that she is going to die.
An adolescent client with terminal cancer tells the nurse that she does not want any more treatment, even though her parents are planning for her to participate in a study trial that involves aggressive chemotherapy. Which action by the nurse is the most appropriate? A) Tell the client that the decision is her parents' and she has to participate in the study. B) Tell her that, at 16, she can make her own decisions no matter what her parents want. C) Request that the parents and daughter meet together with the healthcare team to discuss options and the implications of various choices. D) Tell her not to worry because her parents want the best for her.
Answer: C Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers. However, the Patient Self- Determination Act of 1990 limits the legal rights of individuals younger than 18 to make their own healthcare decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and healthcare team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice. Telling her not to worry does not address the problem.
An older school-age child is brought to the emergency department after a car accident. The parents witness and stare at the resuscitation scene unfolding before them. The child is not responding to the resuscitative efforts after 30 minutes. Which is the best communication strategy for the nurse to use in this situation? A) Ask the parents whether they would like resuscitative efforts to be continued at this point. B) Ask the parents to stand at the foot of the cart to watch. C) Inform the parents that resuscitative efforts have not been effective and are not beneficial to the child. D) Ask the parents to leave until the child has stabilized.
Answer: C Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child. When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that the therapy is not effective in reversing overwhelming illness or brain damage. All other interventions mentioned are not effective communication strategies in this situation.
The nurse is caring for a dying child. Which nursing action supports the primary goal for a dying child? A) Keep the child entertained so she does not think about dying. B) Ensure that a good relationship is maintained with the family. C) Administer pain medication as ordered. D) Maintain a busy schedule for child and family members.
Answer: C Children with life-limiting conditions should receive palliative care in much the same way it is provided to adults. The major goal for the dying child is to promote comfort and keep the child pain-free by providing analgesia to promote optimal pain relief. Maintaining a good relationship is important but not a major goal for the child's care. Keeping the child entertained is good, but the client needs to voice her feelings about death and dying. A dying child does not have the energy to maintain a busy schedule.
What is an example of chronic pain? A) Pain that precedes injury B) Pain that follows injury and ends when healing is complete C) Pain that is felt during injury and immediately after D) Pain that outlasts the healing process
Answer: D Chronic pain is pain that lasts beyond the expected time of healing, usually for at least 6 months; it does not always have a known cause. Pain can range from mild to severe, and autonomic responses decrease over time as the body adapts to the persistent pain impulses. Chronic pain does not precede injury, nor does it subside immediately after injury, and it may not be related to an injury. It does not end when healing is complete.
A preschool-age client's IV has infiltrated and must be restarted immediately for medication administration. There is no time for placing local anesthetic cream on the skin to decrease the pain associated with the procedure. Which complementary therapy would be most helpful when placing the IV for this pediatric client? A) Moderate sedation B) Restraint using a "mummy wrap" C) Anesthesia D) Distraction using bubbles
Answer: D Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure. Playing games such as blowing bubbles would provide distraction for this pediatric client and be a valid nursing intervention. All the other choices are not considered complementary therapies and are inappropriate for the situation.