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NUR-158 Final Review Exam Study
Guide Questions and Answers 2025
Which intervention is an atraumatic way to encourage deep breathing in children? Select
all that apply. One, some, or all responses may be correct.
1) Have the child pretend to suck up liquid with a straw.
2) Ask the child to "blow out" the light on an otoscope or pocket flashlight.
3) Place a small tissue on the top of a pencil and ask the child to blow off the tissue.
4) Apply firm pressure on the stethoscopes' chest piece but not enough to prevent
vibrations and transmission of sound.
5) Place a cotton ball in the child's palm, ask the child to blow the ball into the air, and
have the parent catch it.
A) 1,2
B) 1,2,3
C) 4,5
D) 2,3,5
E) All
F) None
D) 2,3,5
Rationale
Atraumatic ways in which nurses can encourage deep breathing in children include
asking the child to "blow out" the light on an otoscope or pocket flashlight; placing a
small tissue on the top of a pencil and asking the child to blow off the tissue; and placing
a cotton ball in the child's palm, then asking the child to blow the ball into the air and
having the parent catch it. Having the child pretend to suck up liquids with a straw is not
an effective way to encourage deep breaths. Applying firm pressure on the chest piece
but not enough to prevent vibrations and transmission of sound is helpful in obtaining
effective auscultation but not effective in encouraging deep breaths.
p. 118
Which assessment tool would the nurse use when assessing a 4-year-old child for pain
on admission assessment?
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A) FACES Pain Rating Scale
B) Numerical rating scale
C) Pain Assessment Tool
D) Postoperative Pain Score
A) FACES Pain Rating Scale
Rationale
The nurse uses the FACES Pain Rating Scale, which shows a series of facial expressions
depicting the degrees of pain. The child can easily point at the face that represents how
they are feeling. The numerical rating scale is used for children more than 8 years old,
whereby the child can rate the intensity of pain on a scale of zero to 10. The Pain
Assessment Tool is used to examine pain in infants. The Postoperative Pain Score is used
for testing postoperative pain in infants less than 7 months old.
p. 140
What is the youngest age at which a nurse would use the FACES Pain Rating Scale for
pain assessment?
A) 1 year
B) 2 years
C) 3 years
D) 4 years
C) 3 years
Rationale
The FACES Pain Rating Scale can be used in children as young as 3 years. One or 2 years
of age is too young for the FACES scale. Four years old is not the youngest age for which
the FACES scale is appropriate.
p. 140
A nurse is assessing the pain of a child using the FACES pain rating scale. The child picked
the second face 2 hours earlier. The child chooses the fourth face when asked how the
pain feels now. Which statement describes the nurse's interpretation from the face the
child has chosen?
A) Pain hurts a little bit.
B) Pain hurts a whole lot.
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C) Pain hurts even more.
D) Pain hurts a little more.
C) Pain hurts even more.
Rationale
The fourth face would be a 3 which means hurts even more. Remember there is a zero
face meaning no pain. A score of one is given if the pain hurts a little bit. A score of four,
the fifth face, is given if the pain hurts a whole lot. A score of two is given if the pain
hurts a little more.
pp. 140-141
A 5-month-old infant has mild grimacing, restless leg movements, and an increased
activity level with rigid body. The infant is difficult to console and cries steadily but
weakly. What score would the nurse assign on the Face, Legs, Activity, Cry, Consolability
(FLACC) Behavioral Pain Scale tool for the infant?
A) 6
B) 7
C) 8
D) 9
B) 7
Rationale
The FLACC Behavioral Pain Scale Assessment tool includes five categories of behavior:
facial expression, leg movement, activity level, cry, and consolability. It measures pain by
quantifying pain behaviors with scores ranging from zero (no pain behaviors) to 10 (most
possible pain behaviors).
Mild facial expression = 1 + moderate leg movement = 1 + increased activity = 2 +
increased consolability = 2 + weak cry = 1 = 7 total.
p. 138
Which action by the nurse is best to help prevent anxiety when checking the vital signs
of a preschool-age child?
A) Perform the procedure quickly
B) Ask the parents to stay out of the room
C) Ask whether the child is feeling scared
D) Inform the child that the procedure is not harmful
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A) Perform the procedure quickly
Rationale
The nurse performs the procedure quickly to alleviate the child's anxiety, because the
child feels that medical equipment can cause bodily harm. The nurse advises the parents
to stay with the child so that the child feels protected. Asking if the child is feeling scared
may cause increased anxiety. Informing the child that the procedure Is not harmful does
not help to relieve the child's fears.
p. 656
The nurse can take which action to make a hospitalized 7-year-old more comfortable
during the time of physical restriction due to a cast? Select all that apply. One, some, or
all responses may be correct.
1) Provide video game systems.
2) Ask parents to visit every day.
3) Provide musical or tactile toys.
4) Move the bed toward the window.
5) Perform the patient's self-care for the child.
A) 1,2
B) 1,3,4
C) 4,5
D) 1,2,4,5
E) All
F) None
B) 1,3,4
Rationale
Video games can serve as a distraction for the child. Increase in sensory freedom can be
accomplished through musical and tactile toys or by moving the bed toward the window.
The nurse can encourage the parents to visit the child, but cannot instruct them to do
so. Teaching self-care according to the child's ability allows independence and a sense of
control.
p. 655
Which action by the nurse helps to ease the child's feelings of separation when the
parents are unable to visit for long hours?
MBA EXIT
NUR-158 Final Review Exam Study
Guide Questions and Answers 2025
Which intervention is an atraumatic way to encourage deep breathing in children? Select
all that apply. One, some, or all responses may be correct.
1) Have the child pretend to suck up liquid with a straw.
2) Ask the child to "blow out" the light on an otoscope or pocket flashlight.
3) Place a small tissue on the top of a pencil and ask the child to blow off the tissue.
4) Apply firm pressure on the stethoscopes' chest piece but not enough to prevent
vibrations and transmission of sound.
5) Place a cotton ball in the child's palm, ask the child to blow the ball into the air, and
have the parent catch it.
A) 1,2
B) 1,2,3
C) 4,5
D) 2,3,5
E) All
F) None
D) 2,3,5
Rationale
Atraumatic ways in which nurses can encourage deep breathing in children include
asking the child to "blow out" the light on an otoscope or pocket flashlight; placing a
small tissue on the top of a pencil and asking the child to blow off the tissue; and placing
a cotton ball in the child's palm, then asking the child to blow the ball into the air and
having the parent catch it. Having the child pretend to suck up liquids with a straw is not
an effective way to encourage deep breaths. Applying firm pressure on the chest piece
but not enough to prevent vibrations and transmission of sound is helpful in obtaining
effective auscultation but not effective in encouraging deep breaths.
p. 118
Which assessment tool would the nurse use when assessing a 4-year-old child for pain
on admission assessment?
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,MBA EXIT
A) FACES Pain Rating Scale
B) Numerical rating scale
C) Pain Assessment Tool
D) Postoperative Pain Score
A) FACES Pain Rating Scale
Rationale
The nurse uses the FACES Pain Rating Scale, which shows a series of facial expressions
depicting the degrees of pain. The child can easily point at the face that represents how
they are feeling. The numerical rating scale is used for children more than 8 years old,
whereby the child can rate the intensity of pain on a scale of zero to 10. The Pain
Assessment Tool is used to examine pain in infants. The Postoperative Pain Score is used
for testing postoperative pain in infants less than 7 months old.
p. 140
What is the youngest age at which a nurse would use the FACES Pain Rating Scale for
pain assessment?
A) 1 year
B) 2 years
C) 3 years
D) 4 years
C) 3 years
Rationale
The FACES Pain Rating Scale can be used in children as young as 3 years. One or 2 years
of age is too young for the FACES scale. Four years old is not the youngest age for which
the FACES scale is appropriate.
p. 140
A nurse is assessing the pain of a child using the FACES pain rating scale. The child picked
the second face 2 hours earlier. The child chooses the fourth face when asked how the
pain feels now. Which statement describes the nurse's interpretation from the face the
child has chosen?
A) Pain hurts a little bit.
B) Pain hurts a whole lot.
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,MBA EXIT
C) Pain hurts even more.
D) Pain hurts a little more.
C) Pain hurts even more.
Rationale
The fourth face would be a 3 which means hurts even more. Remember there is a zero
face meaning no pain. A score of one is given if the pain hurts a little bit. A score of four,
the fifth face, is given if the pain hurts a whole lot. A score of two is given if the pain
hurts a little more.
pp. 140-141
A 5-month-old infant has mild grimacing, restless leg movements, and an increased
activity level with rigid body. The infant is difficult to console and cries steadily but
weakly. What score would the nurse assign on the Face, Legs, Activity, Cry, Consolability
(FLACC) Behavioral Pain Scale tool for the infant?
A) 6
B) 7
C) 8
D) 9
B) 7
Rationale
The FLACC Behavioral Pain Scale Assessment tool includes five categories of behavior:
facial expression, leg movement, activity level, cry, and consolability. It measures pain by
quantifying pain behaviors with scores ranging from zero (no pain behaviors) to 10 (most
possible pain behaviors).
Mild facial expression = 1 + moderate leg movement = 1 + increased activity = 2 +
increased consolability = 2 + weak cry = 1 = 7 total.
p. 138
Which action by the nurse is best to help prevent anxiety when checking the vital signs
of a preschool-age child?
A) Perform the procedure quickly
B) Ask the parents to stay out of the room
C) Ask whether the child is feeling scared
D) Inform the child that the procedure is not harmful
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, MBA EXIT
A) Perform the procedure quickly
Rationale
The nurse performs the procedure quickly to alleviate the child's anxiety, because the
child feels that medical equipment can cause bodily harm. The nurse advises the parents
to stay with the child so that the child feels protected. Asking if the child is feeling scared
may cause increased anxiety. Informing the child that the procedure Is not harmful does
not help to relieve the child's fears.
p. 656
The nurse can take which action to make a hospitalized 7-year-old more comfortable
during the time of physical restriction due to a cast? Select all that apply. One, some, or
all responses may be correct.
1) Provide video game systems.
2) Ask parents to visit every day.
3) Provide musical or tactile toys.
4) Move the bed toward the window.
5) Perform the patient's self-care for the child.
A) 1,2
B) 1,3,4
C) 4,5
D) 1,2,4,5
E) All
F) None
B) 1,3,4
Rationale
Video games can serve as a distraction for the child. Increase in sensory freedom can be
accomplished through musical and tactile toys or by moving the bed toward the window.
The nurse can encourage the parents to visit the child, but cannot instruct them to do
so. Teaching self-care according to the child's ability allows independence and a sense of
control.
p. 655
Which action by the nurse helps to ease the child's feelings of separation when the
parents are unable to visit for long hours?
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