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NCLEX Question of the Day
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The nurse is assessing a 5-year-old child admitted with pneumonia who reports abdominal pain. The child is lying rigidly in bed and grimacing. Which action should the nurse take first to assess the child's pain?
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Ask the parent how much pain they think the child is in.
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Observe the child's heart rate and respiratory rate.
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Correct answer Use the FACES Pain Rating Scale with the child.
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Administer the prescribed PRN analgesic immediately.
Rationale
Self-report is the most reliable indicator of pain. A 5-year-old child (preschool age) is capable of self-reporting pain using an appropriate tool. The FACES Pain Rating Scale uses simple facial expressions and is validated for use in children ages 3 and older. Assessing the child's self-reported pain level is the first step in managing their pain effectively.
While parental input is valuable, the child's self-report should be obtained first whenever possible. Vital signs (heart rate, respiratory rate) can increase with pain but are non-specific and can be influenced by other factors like fever or anxiety; they should be considered alongside self-report and behavioral observation, not as the primary assessment method. Administering analgesics should occur after a pain assessment confirms the need and determines the appropriate intervention level, not before.
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