RATIONALES NEXT GEN NGN included VERIFIED FOR
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A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales
should the nurse use?
A.FACES
B.Numeric
C.CRIES
D.Visual analog A
The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and
older. This scale allows the toddler to point to the face that depicts their current level of pain.
The nurse can then determine the need for pain management.
A nurse is planning an educational program to teach parents about protecting their children from
sunburns. Which of the following instructions should the nurse plan to include?
A."allow your child to play outside during the hours between 10:00am and 2:00pm."
B."choose a waterproof sunscreen with a minimum SPF of 15."
C."dress you child in loose weave polyester fabric prior to sun exposure."
D."reapply sunscreen every 4 hours." B
The nurse should instruct parents to avoid allowing their children to play outside during the
hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn
during this time.
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The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for
children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of
sunburn.
The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun
exposure to protect the skin from the sun.
The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.
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A nurse is performing hearing screenings for children at a community health fair. Which of the
following children should the nurse refer to a provider for a more extensive hearing
evaluation?
a. An 18 month old toddler who has unintelligible speech
b. A 3 month old infant who has exaggerated startle response
c. A 4 year old preschooler who prefers playing with others rather than alone
d. An 8 month old infant who is not yet making babbling sounds D
The nurse should refer a toddler who does not possess intelligible speech by the age of 24
months to a provider for a more extensive evaluation of hearing.
The nurse should refer infants who are under the age of 4 months and lack a startle response to
a provider for a more extensive evaluation of hearing.
The nurse should refer a preschooler who prefers playing alone and avoids interaction with
others to a provider for a more extensive evaluation of hearing.
The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a
provider for a more extensive evaluation of hearing.
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is
experiencing acute vomiting and diarrhea. Which of the following manifestations should the
nurse identify as an indication that the infant has moderate to severe dehydration?
A.HR 124
B.Increased tear production
C.Sunken anterior fontanel
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D.Capillary refill 2 seconds C
A heart rate of 124/min is within the expected reference range of 106 to 186 /min for a 3- to
the 5-month-old infant. The nurse should expect the infant who has moderate to severe
dehydration to have tachycardia.
An infant who has moderate to severe dehydration is more likely to have an absence of tears
rather than increased tear production.
The nurse should recognize that a sunken anterior fontanel is an indication of moderate to
severe dehydration due to the acute loss of fluid.
A capillary refill of 2 seconds is within the expected reference range of 2 seconds or less for a 3-
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