Introduction
Pediatric pain assessment and management represents one of the most critical competencies for nurses pursuing Certified Pediatric Nurse (CPN) certification, as inadequate pain control in children can lead to both immediate suffering and long-term psychological consequences. Unlike adult patients, pediatric patients present unique challenges in pain assessment due to developmental variations, limited verbal communication abilities in younger children, and diverse behavioral responses to pain across different age groups. The CPN examination extensively tests knowledge of developmentally appropriate pain assessment tools, ranging from behavioral scales like FLACC for infants and toddlers to self-report scales for school-age children and adolescents. Effective pain management requires not only understanding pharmacological interventions—including proper dosing calculations, medication selection, and monitoring for adverse effects—but also integrating non-pharmacological strategies such as distraction, positioning, and comfort measures that are tailored to each child’s developmental stage. Cultural competence plays a vital role in pain assessment, as families from different backgrounds may have varying beliefs about pain expression, medication use, and appropriate interventions. Nurses must also navigate complex ethical considerations, including advocating for adequate pain control while addressing parental concerns about medication side effects and addiction, which are often based on misconceptions. The ability to recognize pain in nonverbal or cognitively impaired children through careful observation of behavioral cues, physiological indicators, and changes in usual patterns is essential for comprehensive pediatric nursing practice. Understanding the principles of around-the-clock dosing for chronic pain conditions versus PRN administration for acute pain, as well as the safe use of patient-controlled analgesia in appropriate age groups, demonstrates the depth of knowledge required for CPN certification. Additionally, condition-specific pain management strategies, such as avoiding cold application in sickle cell disease and recognizing the unique needs of children with cancer or chronic conditions, reflect the specialized expertise expected of certified pediatric nurses. These practice questions are designed to test your ability to apply evidence-based pain management principles across diverse clinical scenarios, preparing you for both the CPN examination and excellence in pediatric nursing practice.
Practice Questions
Question 1: A 4-year-old child is admitted to the pediatric unit following an appendectomy. Which pain assessment tool is MOST appropriate for this patient?
A) Numeric Rating Scale (0-10)
B) FLACC Scale (Face, Legs, Activity, Cry, Consolability)
C) Visual Analog Scale
D) McGill Pain Questionnaire
Correct Answer: B
Explanation: The FLACC Scale is most appropriate for children aged 2 months to 7 years who cannot reliably self-report pain. It assesses five behavioral indicators: facial expression, leg movement, activity, cry, and consolability. The Numeric Rating Scale (A) is better suited for children 8 years and older who can understand numerical concepts. The Visual Analog Scale (C) requires abstract thinking typically not developed until age 7-8. The McGill Pain Questionnaire (D) is designed for adults and requires advanced verbal skills.
Question 2: A 6-month-old infant is receiving immunizations. Which non-pharmacological intervention is MOST effective for pain management during the procedure?
A) Distraction with a mobile toy
B) Oral sucrose solution and breastfeeding
C) Deep breathing exercises
D) Guided imagery
Correct Answer: B
Explanation: Oral sucrose solution (24% sucrose) combined with breastfeeding or non-nutritive sucking has strong evidence for reducing procedural pain in infants. The sweet taste triggers endogenous opioid release, providing analgesic effects. Distraction with toys (A) is less effective in infants compared to older children. Deep breathing exercises (C) and guided imagery (D) require cognitive abilities beyond an infant’s developmental capacity and are more appropriate for school-age children and adolescents.
Question 3: A 10-year-old child with sickle cell disease reports pain level of 8/10 in the lower extremities. The child received morphine 30 minutes ago with minimal relief. What is the nurse’s PRIORITY action?
A) Reassess pain in another 30 minutes
B) Apply heat to the affected areas
C) Notify the healthcare provider immediately
D) Encourage the child to ambulate
Correct Answer: C
Explanation: When pain management is inadequate after appropriate intervention, the nurse must notify the healthcare provider immediately to reassess the pain management plan and consider alternative or additional interventions. Sickle cell pain crises require aggressive pain management. Waiting another 30 minutes (A) delays necessary treatment. While heat application (B) can be helpful, it should not replace pharmacological intervention when pain is severe. Encouraging ambulation (D) is inappropriate during an acute pain crisis and could worsen the condition.
Question 4: Which statement by a parent indicates understanding of acetaminophen administration for their 2-year-old child weighing 12 kg?
A) “I can give up to 1000 mg every 4 hours as needed.”
B) “I should give 180 mg every 4-6 hours, not exceeding 5 doses in 24 hours.”
C) “I can alternate with ibuprofen every 2 hours for better pain control.”
D) “I should give the medication only at bedtime to help with sleep.”
Correct Answer: B
Explanation: The recommended acetaminophen dose for children is 10-15 mg/kg every 4-6 hours, with a maximum of 5 doses in 24 hours (not exceeding 75 mg/kg/day or 4000 mg/day). For a 12 kg child, this equals 120-180 mg per dose. Option A exceeds safe dosing limits and could cause hepatotoxicity. While alternating acetaminophen and ibuprofen (C) is sometimes done, they should not be given every 2 hours—each medication should maintain its own dosing schedule. Option D is incorrect because pain medication should be given around-the-clock for consistent pain control, not just at bedtime.
Question 5: A nurse is caring for a 14-year-old postoperative patient who rates pain as 3/10 but exhibits tachycardia, diaphoresis, and muscle tension. What is the BEST interpretation of this situation?
A) The patient is exaggerating pain symptoms for attention
B) The patient’s self-report is accurate; vital signs are unrelated
C) The patient may be underreporting pain due to fear or stoicism
D) The patient is experiencing anxiety, not pain
Correct Answer: C
Explanation: Adolescents may underreport pain due to various factors including fear of injections, desire to appear brave, concern about medication side effects, or cultural influences. The physiological signs (tachycardia, diaphoresis, muscle tension) suggest the patient is experiencing more pain than reported. While self-report is the gold standard for pain assessment, behavioral and physiological indicators should also be considered, especially when they are inconsistent with the verbal report. The nurse should explore reasons for potential underreporting and provide reassurance. Options A and D dismiss the patient’s experience, and option B ignores important clinical indicators.
Question 6: A 3-year-old child is scheduled for a painful dressing change. Which approach demonstrates developmentally appropriate pain management?
A) Explain the procedure in detail 2 hours before to reduce anxiety
B) Provide simple explanation immediately before, offer choices, and use distraction
C) Perform the procedure quickly without warning to minimize anticipatory anxiety
D) Tell the child it won’t hurt to prevent fear
Correct Answer: B
Explanation: For toddlers and preschoolers, preparation should occur immediately before the procedure (not hours in advance) using simple, concrete terms. Offering limited choices (e.g., “Which arm?” or “Do you want to sit or lie down?”) provides a sense of control. Distraction techniques like bubbles, music, or toys are highly effective at this age. Explaining too far in advance (A) increases anxiety as young children have limited time concepts. Performing procedures without warning (C) violates trust and increases trauma. Never lie to children about pain (D) as this destroys trust and makes future procedures more difficult.
Question 7: Which assessment finding in a nonverbal 18-month-old child would MOST strongly indicate pain?
A) Decreased appetite for one meal
B) Facial grimacing, guarding of abdomen, and inconsolable crying
C) Sleeping more than usual
D) Decreased interest in toys for 30 minutes
Correct Answer: B
Explanation: The combination of facial grimacing, guarding (protective behavior), and inconsolable crying represents multiple behavioral indicators of significant pain in a nonverbal child. These are specific, observable pain behaviors that warrant immediate assessment and intervention. Decreased appetite (A), increased sleep (C), and decreased play interest (D) can indicate pain but are less specific and could be related to many other factors. When assessing pain in nonverbal children, nurses should look for clusters of behavioral indicators rather than relying on single signs.
Question 8: A nurse is teaching parents about pain management for their child with juvenile idiopathic arthritis. Which statement should be included?
A) “Pain medication should only be given when pain becomes severe.”
B) “Regular physical activity should be avoided to prevent pain.”
C) “Around-the-clock pain medication maintains steady pain control and prevents breakthrough pain.”
D) “Your child will become addicted if pain medication is used regularly.”
Correct Answer: C
Explanation: For chronic pain conditions like juvenile idiopathic arthritis, around-the-clock (scheduled) pain medication maintains consistent therapeutic levels and prevents breakthrough pain, which is more difficult to control once it occurs. This approach is more effective than PRN (as-needed) dosing for chronic conditions. Waiting until pain is severe (A) makes it harder to achieve adequate control. Regular physical activity (B) is actually important for maintaining joint function and should be encouraged with appropriate pain management. Addiction (D) is extremely rare in children receiving appropriate pain management for legitimate medical conditions; this misconception often leads to inadequate pain control.
Question 9: A 7-year-old child with a fractured femur is receiving patient-controlled analgesia (PCA). Which finding requires IMMEDIATE nursing intervention?
A) Respiratory rate of 10 breaths per minute with shallow breathing
B) Pain rating of 4/10 on the numeric scale
C) The child pressing the PCA button every 10 minutes
D) Oxygen saturation of 96% on room air
Correct Answer: A
Explanation: Respiratory depression (rate <12 breaths per minute in a school-age child, especially with shallow breathing) is a serious adverse effect of opioid analgesia and requires immediate intervention. The nurse should stop the PCA, stimulate the child, administer oxygen, and prepare to give naloxone if needed. A pain rating of 4/10 (B) is within acceptable range for postoperative pain. Frequent PCA button pressing (C) is expected and the lockout interval prevents overdose. An oxygen saturation of 96% (D) is within normal limits, though the respiratory rate is the more concerning finding.
Question 10: Which cultural consideration is MOST important when assessing pain in a pediatric patient?
A) All children from the same culture express pain identically
B) Cultural background may influence pain expression, but individual assessment is essential
C) Pain assessment tools are universally effective across all cultures
D) Parents’ cultural beliefs should be disregarded in favor of standard protocols
Correct Answer: B
Explanation: While cultural background can influence how children and families perceive, express, and respond to pain, individual variation within cultures is significant. Nurses must conduct individualized assessments while being culturally sensitive. Some cultures encourage stoicism while others permit open expression of pain. Option A incorrectly assumes cultural homogeneity. Option C ignores that some pain assessment tools may not translate well across cultures or languages. Option D is culturally insensitive and violates family-centered care principles. Effective pain management requires understanding both cultural influences and individual patient/family preferences.
Question 11: A nurse is preparing to administer ibuprofen to a 5-year-old child. Which condition would be a CONTRAINDICATION?
A) Mild dehydration from decreased oral intake
B) History of asthma
C) Active varicella (chickenpox) infection
D) Mild headache
Correct Answer: C
Explanation: Ibuprofen and other NSAIDs should be avoided in children with varicella or influenza due to the potential association with Reye’s syndrome, though this link is stronger with aspirin. Additionally, NSAIDs can mask fever, which is important for monitoring viral infections. Mild dehydration (A) is a relative contraindication but not absolute; however, hydration status should be addressed. While NSAIDs should be used cautiously in asthma (B), they are not absolutely contraindicated unless the child has aspirin-sensitive asthma. Mild headache (D) is actually an indication for ibuprofen use, not a contraindication.
Question 12: A 12-year-old patient is using a patient-controlled analgesia (PCA) pump. The nurse observes the patient’s parent pressing the PCA button while the child sleeps. What is the nurse’s BEST response?
A) Thank the parent for being attentive to the child’s needs
B) Explain that only the patient should press the button to prevent overdose
C) Document the observation without intervening
D) Increase the basal rate to reduce the need for bolus doses
Correct Answer: B
Explanation: PCA by proxy (someone other than the patient pressing the button) is dangerous and can lead to oversedation and respiratory depression. Only the patient should control the PCA button because pain and sedation are self-limiting—when adequately medicated, the patient will sleep and not press the button. The nurse must educate the parent about this safety issue immediately. Thanking the parent (A) reinforces dangerous behavior. Simply documenting (C) without intervention fails to address a serious safety concern. Increasing the basal rate (D) does not address the immediate safety issue and could increase the risk of adverse effects.
Question 13: Which pain assessment approach is MOST appropriate for a 15-year-old patient with cognitive impairment?
A) Rely solely on the patient’s self-report using a numeric scale
B) Use a behavioral pain assessment tool and observe for pain indicators
C) Assume the patient cannot feel pain due to cognitive impairment
D) Base pain assessment only on vital sign changes
Correct Answer: B
Explanation: For patients with cognitive impairment who cannot reliably self-report, behavioral pain assessment tools (such as the FLACC scale or r-FLACC for revised version) are most appropriate. These tools assess observable behaviors like facial expression, body movements, vocalization, and consolability. While attempting to obtain self-report is important (A), it may not be reliable, and behavioral assessment provides crucial additional information. Option C reflects a dangerous misconception—individuals with cognitive impairment do feel pain. Vital signs alone (D) are not reliable pain indicators as they can be affected by many factors and may not change even with significant pain.
Question 14: A nurse is teaching a parent about administering oral morphine at home for a child with cancer pain. Which statement by the parent indicates need for FURTHER teaching?
A) “I should give the medication at the same times each day for better pain control.”
B) “I’ll increase fiber and fluids in my child’s diet to prevent constipation.”
C) “If my child vomits within 15 minutes of taking the medication, I’ll give another full dose.”
D) “I’ll monitor for excessive drowsiness and difficulty breathing.”
Correct Answer: C
Explanation: If a child vomits shortly after taking oral medication, the parent should contact the healthcare provider for guidance rather than automatically administering another full dose, as some medication may have been absorbed and redosing could lead to overdose. The provider may recommend waiting and monitoring, giving a partial dose, or using an alternative route. Scheduled dosing (A) is correct for chronic pain management. Increasing fiber and fluids (B) is appropriate as constipation is a common side effect of opioids. Monitoring for respiratory depression and excessive sedation (D) is essential for safe opioid use.
Question 15: A 9-year-old child with sickle cell disease is being discharged with a pain management plan. Which teaching point is MOST important for the nurse to emphasize?
A) “Apply ice packs to painful areas for 20 minutes every hour.”
B) “Drink at least 8 glasses of water daily and avoid extreme temperatures.”
C) “Restrict physical activity to prevent pain crises.”
D) “Take pain medication only when pain becomes unbearable.”
Correct Answer: B
Explanation: Adequate hydration is crucial in preventing sickle cell pain crises as dehydration promotes sickling of red blood cells. Avoiding extreme temperatures (both hot and cold) also helps prevent crises. Ice application (A) is contraindicated in sickle cell disease as cold causes vasoconstriction and can worsen sickling and pain; heat is preferred. While excessive strenuous activity should be avoided, complete restriction (C) is unnecessary and can negatively impact quality of life—moderate activity with adequate hydration is appropriate. Pain medication should be taken at the first sign of pain (D), not when it becomes unbearable, as early intervention is more effective.