Question

The nurse is caring for a 5 year old child who underwent a painful surgical procedure earlier in the day. The nurse notes the child has not reported pain to any of the nursing staff. What action by the nurse is indicated?

a. contact the physician to report the child's condition
b. administer prophylactic analgesics
c. observe for behavioral cues consistent with pain
d. encourage the child to report pain

Answer 1

The nurse should observe for behavioral cues consistent with pain and use child-appropriate tools like the Wong-Baker Faces Scale to assess pain since the child has not verbalized any discomfort. The Correct Answer is Option. C.

Step-by-step explanation:

The nurse caring for a 5-year-old child who has not reported pain after undergoing a surgical procedure should observe for behavioral cues consistent with pain. Young children may not verbalize their discomfort, so nurses must be vigilant in looking for non-verbal signs such as restlessness, crying, facial expressions, and changes in sleep or eating patterns.

Utilizing tools like the Wong-Baker Faces Scale, which is designed for children, can aid in assessing the child's pain levels. Administering prophylactic analgesics without evidence of pain can be inappropriate and may lead to unnecessary medication exposure. Encouraging the child to report pain is also a valuable practice, as it empowers the child to communicate their needs directly.