Question

1. a nurse is assessing a 4-year-old child following a surgical procedure. which of the following pain rating scales should the nurse use?

a. Boucher pain rating scale.

b. word-graphic rating scale.

c. numeric rating scale.

d. visual analog scale.

2. a school nurse is assessing a child who fell from playground equipment and landed head-first. which of the following manifestations should the nurse recognize as indicating the presence of increased ICP?

a. report of diplopia.

b. hyperactivity.

c. nuchal rigidity.

d. report of sore throat.

3. a nurse is assessing an infant who has hydrocephalus. which of the following clinical manifestations should the nurse expect?

a. depressed scalp veins.

b. sunken anterior fontanels.

c. bulging eyes.

d. separated cranial sutures.

4. a nurse is preparing a teaching plan for the parents of a school age child who has asthma. which of the following manifestations should the nurse include as an indication of an exacerbation of asthma.

a. green zone reading on peak expiratory flow meter.

b. rhinitis.

c. axillary temp of 37.2 C (99 F).

d. hacking, nonproductive cough.

Answer 1

1- Boucher Pain rating scale

(as it use both pictures and numbers The pictures can be used for preschool children, while older children can also use the numerical scale)

2- Hyperactivity

(Hyperactivity is a state of being unusually or abnormally active. Abnormal behaviour is the first thing to look for in ICP)

3- Buldging eyes

4- hacking non productive cough

(Coughing is increased when child id introduced to any asthma trigger like dust or any other allergen)