NURS 3450 Ch 9 ATI Pediatric Pain Management – Flashcards

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question
Children of what age can perceive pain?
answer
All ages
question
Unrelieved pain is a major _____ and _____ stressor.
answer
Physiologic, psycologic
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What can repeated pain in infants lead to?
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Future sensitivity to pain
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What can self-protective behavior due to pain cause?
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Delayed healing
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List pain behaviors for acute pain.
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Short attention span, irritability, grimacing, posturing, limb flexion, sleep disturbances, lethargy, withdrawal
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List pain behaviors for chronic pain.
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Physiologic adaptation may mask signs
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How should a developmentally appropriate pain scale be chosen?
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Determine child's ability to demonstrate concepts of degree, rank order, estimation, and classification
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List the 6 types of self-report scales.
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-Body outline -Faces -Oucher -Poker chip -Numeric rating -World-graphic rating
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List the factors that can have a positive or negative effect on pain perception.
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-Age -Developmental stage -Chronic or acute disease -Socioeconomic status -Prior experiences with pain -Personality -Family dynamics -Culture
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A loud cry is a developmental characteristic of pain in what age group?
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Young infant and older infant
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A rigid body/thrashing is a developmental characteristic of pain in what age group?
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Young infant
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A local reflex withdrawal from a painful stimulus is a developmental characteristic of pain in what age group?
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Young infant
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Lowered and drawn together eyebrows are a developmental characteristic of pain in what age group?
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Young infant
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Tightly closed eyes are a developmental characteristic of pain in what age group?
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Young infant
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An open mouth in a squarish shape is a developmental characteristic of pain in what age group?
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Young infant
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A facial expression of pain is a developmental characteristic of pain in what age group?
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Older infant
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Deliberate withdrawal from pain is a developmental characteristic of pain in what age group?
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Older infant
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A loud cry/scream is a developmental characteristic of pain in what age group?
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Toddler; school age
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Verbal expression of pain is a developmental characteristic of pain in what age group?
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Toddler; School age
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Thrashing of extremities is a developmental characteristic of pain in what age group?
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Toddler; school age
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Attempt to push away or avoid a painful stimulus is a developmental characteristic of pain in what age group?
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Toddler; school age
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Noncooperation is a developmental characteristic of pain in what age group?
answer
Toddler; school age
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Clinging to a significant person is a developmental characteristic of pain in what age group?
answer
Toddler; school age
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What is the main difference between developmental characteristics of pain in toddlers and school age?
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-Toddler: behaviors occur in anticipation of painful stimulus -School age: behaviors are less intense in the anticipatory phase and more intense with painful stimulus
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Stalling behavior is a developmental characteristic of pain in what age group?
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School age
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Muscular rigidity is a developmental characteristic of pain in what age group?
answer
School age
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Verbal expression of pain with less protesting is a developmental characteristic of pain in what age group?
answer
Adolescent
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Muscle tension with body control is a developmental characteristic of pain in what age group?
answer
Adolescent
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What is the minimum age to use self report pain scales?
answer
4 years
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What assessment tool is appropriate for children >3 years old?
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FACES
question
What assessment tool is appropriate for children 2 months-7 years?
answer
FLACC
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What assessment tool is appropriate for children aged 3 years to 13 years
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Oucher
question
What is the minimum age to use a numeric scale to rate pain?
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5 years
question
What assessment tool is appropriate to use for non-communicating children aged 3-18 years?
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Non-communicating child's pain checklist
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How does the FLACC work?
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Pain is rated by the healthcare professional on a scale of 0-10 by assessing behaviors of the child in 5 categories.
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What does F stand for in FLACC?
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Face
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If a child scores a 0 for the F component of the FLACC assessment, what does this mean?
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They have a smile or no expression
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If a child scores a 1 for the F component of the FLACC assessment, what does this mean?
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They occasionally frown or grimace, may look withdrawn
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If a child scores a 2 for the F component of the FLACC assessment, what does this mean?
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They frequently or constantly frown, have a clenched jaw, or a quivering chin
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What does L stand for in FLACC?
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Legs
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If a child scores a 0 for the L component of the FLACC assessment, what does this mean?
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Relaxed or normal position
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If a child scores a 1 for the L component of the FLACC assessment, what does this mean?
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Uneasy, restless, tense
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If a child scores a 2 for the L component of the FLACC assessment, what does this mean?
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Kicking or legs drawn up
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What does the A stand for in FLACC?
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Activity
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If a child scores a 0 for the A component of the FLACC assessment, what does this mean?
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Lying quietly ,moves easily, normal position
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If a child scores a 1 for the A component of the FLACC assessment, what does this mean?
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Squirmy, shifting, tense
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If a child scores a 2 for the A component of the FLACC assessment, what does this mean?
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Arched, rigid, jerking
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What does the first C stand for in FLACC?
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Cry
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If a child scores a 0 for the first C component of the FLACC assessment, what does this mean?
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No cry
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If a child scores a 1 for the first C component of the FLACC assessment, what does this mean?
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Moans or whimpers, occasional complaints
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If a child scores a 2 for the first C component of the FLACC assessment, what does this mean?
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crying, screaming, sobbing, frequent complaints
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What does the second C in FLACC stand for?
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Consolability
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If a child scores a 0 for the second C component of the FLACC assessment, what does this mean?
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Content or relaxed
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If a child scores a 1 for the second C component of the FLACC assessment, what does this mean?
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Reassured by occasional touching or hugging, able to distract
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If a child scores a 2 for the second C component of the FLACC assessment, what does this mean?
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Difficult to console or comfort
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How is pain assessed with the FACES scale?
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Child is shown 6 faces of varying degrees of pain; Provider explains each face to the child and asks them to choose a face that best describes how they are feeling; Pain is rated by the child on a scale of 0-5; provider translates that score into 0, 2, 4, 6, 8, or 10
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What does a 0 indicate on the faces scale?
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no hurt
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What does a 1 indicate on the faces scale?
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Hurts a little bit
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What does a 2 indicate on the faces scale?
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Hurts a little more
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What does a 3 indicate on the faces scale?
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Hurts even more
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What does a 4 indicate on the faces scale?
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Hurts a whole lot
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What does a 5 indicate on the faces scale?
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Hurts worst
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Which assessment tool has the same premise as FACES?
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oucher
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Should a parent or caregiver be included in rating a childs pain?
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Yes
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While using the non-communicating child's pain checklist, how long should the provider observe the childs behaviors for?
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1o minutes
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What are the six subcategories of behavior that a provider observes while using the non-communicating childs pain checklist?
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-Vocal -Social -Facial -Activity -Body and limbs -Psychological
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What does a score of 0 in each category of the non-communicating childs pain checklist indicate?
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child is not at all displaying the behaviors that indicate pain
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What does a score of 1 in each category of the non-communicating childs pain checklist indicate?
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Child is displaying the behaviors that indicate pain just a little bit
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What does a score of 2 in each category of the non-communicating childs pain checklist indicate?
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Child is displaying the behaviors that indicate pain fairly often
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What does a score of 3 in each category of the non-communicating childs pain checklist indicate?
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Child is displaying the behaviors that indicate pain very often
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What does an overall score of 6-10 on the non-communicating childs pain checklist indicate?
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Mild pain
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What does an overall score of >11 on the non-communicating childs pain checklist indicate?
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moderate to severe pain
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What factor is highest on the hierarchy of assessment strategies?
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Subjective report of pain
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What factor is second highest on the hierarchy of assessment strategies?
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Painfulness of procedure
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What factor is third highest on the hierarchy of assessment strategies?
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Parents perspective
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What factor is fourth on the hierarchy of assessment strategies?
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Behavioral cues
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What factor is fifth on the hierarchy of assessment strategies?
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Reason to suspect pain; relief with analgesics
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What factor is lowest on the hierarchy of assessment strategies?
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Contributing situational factors
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What does rubor mean?
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redness
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What does calor mean?
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heat
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What does tumor mean?
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swelling
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What does dolor mean?
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Pain
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What types of crying typically indicate pain?
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-High pitched -Tense -Harsh -Non-melodious -Short -Sharp -Loud
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What does a bulge between the eyes and vertical furrows indicate?
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Pain in an infant
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What do raised cheeks indicate in an infant?
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Pain
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What does a broadened and bulging nose in an infant indicate?
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Pain
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What are the four major categories of drugs given to children for pain?
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-Opiods -Non-opiods -Anesthetics -Adjuvants/ co-analgesics
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What are the 5 major non-opiods given to children?
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-Acetaminophen -Aspirin -NSAIDS: Ibuprofen, Cox 2 inhibitors, ketoralac (Toradol)
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What are the 7 major opiods given to children?
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-Fentanyl -Morpine -Hydromorphone -Methadone -Codeine -Hydrocodone -Oxycodone
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Should acetaminophen be given for post operative pain?
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No
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Should acetaminophen be given for a migraine?
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No
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Should acetaminophen be given for vaccination prophylaxis?
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No
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What are the two appropriate routes to administer acetaminophen?
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PO or IV
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What is the appropriate dosage of acetaminophen for a child?
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10-15 mg/kg every 4-6 hours
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In 28-32 weeks gestation, what is the appropriate dosage interval for acetaminophen?
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8-12 hours
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What does the CRIES scale measure?
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C-Crying R-requires O2 for saturation >95 I- increased vital signs E-expression S-sleepless
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What does PIPP stand for?
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Premature infant pain profile
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What does NIPS stand for? What does it measure?
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Neonatal infant pain scale -Expression, cry, breathing, arm and leg movements, arousal state
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What does DSVNI stand for?
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Distress scale for ventilated newborn infants
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List the 4 major multidimensional infant pain scales.
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-CRIES -PIPP -NIPS -DSVNI
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What do the multidimensional infant pain scales measure?
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-The intensity of pain-related distress and pain reactivity
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What are the multidimensional infant pain scales best used for?
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To assess procedural pain, rather than ongoing pain assessments
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What is the minimum age requirement for ibuprofen?
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6 months
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What is the appropriate dosage for ibuprofen for a child?
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4-10 mg/kg/dose every 6-8 hours
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Should ibuprofen be administered for vaccinaiton prophylaxis?
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No
question
What is the only NSAID approved for pain by the FDA for children under the age of 12 years?
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Ibuprogen
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What should be given for mind to moderate pain?
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Tylenol, aspirin, NSAIDS
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What should be given for moderate to severe pain?
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Opiods
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Should codeine be administered for sickle cell crisis?
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No
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What is the minimum age requirement for codeine?
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2 years
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What is the maximum daily dose for codeine?
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3mg/kg
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What is the typical route and dosage for codeine?
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.5-1mg/kg/dose every 4 to 6 hours PRN
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What is the most prescribed opioid for children?
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Codeine
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What oral opioid causes the most nausea?
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Codeine
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What must happen for codeine to be relieve pain?
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It is a pro-drug: it must be metabolized to morphine to relieve pain
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Should morphine be given to treat post operative pain?
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Yes
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Should morphine be given to treat cancer pain?
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Yes
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Should morphine be given to treat chronic pain?
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Yes
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Should morphine be given to treat neuropathic pain?
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No
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Should morphine be given through a PCA?
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No
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Should morphine be given for sickle cell crisis?
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No
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Should morphine be given to premature infants?
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No
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What is the gold standard for opioid analgesics?
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Morphine
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What is the maximum morphine dose?
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-Use second dose every hour if needed with good pain relief and minimal sedation -Maximum dose is the one that results in intolerable side effects
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How can morphine be given?
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PO, IV, IM, SQ
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What is the typical dosage of morphine when used IM, IV, or SC?
answer
.1-.2 mg/kg q2-4 hr
question
What is the maximum dose of morphine when given IM IV or SC?
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15mg/dose or 05-.1 mg/kg
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What is the typical continuous IV infusion rate of morphine for postoperative pain in children 1-15 years?
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.02 mg/kg/hr
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What is the typical dosage of morphine when administered PO?
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.2-5 mg/kg/dose Q4-6 hrs PRN
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What is the minimum age requirement for fentanyl?
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2 years
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Under what circumstances should the oral transmucosal form of fentanyl be administered?
answer
For procedural pain
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What are the three routes that fentanyl should be given to treat post operative pain?
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-Epidural -PCA -Continuous infusion
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What is the dosage of fentanyl for continuous infusion in a neonate?
answer
1mcg/lg IVP
question
What is the dosage of fentanyl for continuous infusion in a ventilated neonate?
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2-5mcg/kg/hr
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Which form of fentanyl oral transmucosal is appropriate for children over 2 years of age: oralet or actiq?
answer
Oralet
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Should meperidine be given for migranes?
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No
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Should meperidine be given for sickle cell crisis?
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No
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Should meperidine be given for chronic pain?
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Yes
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Should meperidine be given through a PCA?
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Yes
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What should meperidine (demerol) be reserved for?
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For very brief courses in patients who have a demonstrated allergy or intolerance to other opiods
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What is the toxic metabolite of meperidine? What can it cause?
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Normeperidine- a cerebral irritant and accumumulation can lead to seizures in otherwise healthy persons
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Should ketorolac be administered for fracture reduction pain?
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no
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Should ketorolac be administered for narcotic sparing effect?
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No
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Should ketorolac be administered for headache?
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No
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What is the minimum age requirement for ketorolac?
answer
16 years
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What is the typical dosage of ketorolac?
answer
.5mg/kg IV q 6 hrs for 48 to 72 hours with analgesics for moderate to severe pain
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Is methadone approved for use in children?
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No
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What is the typical dosage of methadone?
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.2mg/kg q 6 hrs
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What is the dosage of oral methadone for continuous pain, as seen in trauma?
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.3-.4 mg/kg/day divided into several doses
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Is hydromorphone approved for use in children?
answer
No
question
Should hydromorphone be used for analgesia?
answer
No
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What is the typical dosage of hydromorphone for children?
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.05-.1mg/kg/dose PO q hr
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What is the typical dosage of hydromorphone for adolescents?
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1-2mg/dose IV q 4-6 hrs
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Is hydrocodone approved for children?
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No
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Should oxycodone be used for postoperative pain?
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No
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Should oxycodone be used for back pain?
answer
No
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Should oxycodone be used for dental pain?
answer
No
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Should oxycodone be used for neuropathic pain?
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No
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Is oxycodone approved for use in children?
answer
No
question
What is the typical oxycodone dosage?
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.05-.15 mg/kg, up to 5mg per dose, q 4-6 hr
question
Opioid side effects are often related to what?
answer
Dose
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Does tolerance to opioid side effects occur?
answer
Yes, except to constipation
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What are the frequent side effects of opioids?
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-N, V, C -Sedation -Mental clouding -Pruritis
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What are the less frequent side effects of opioids?
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-Myoclonus (jerky contractions) -Urinary retention -Delerium
question
What are the adverse effects of opioids?
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Respiratory depression, cardiovascular collapse, addiction
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What respiratory rate in children qualifies as respiratory depression?
answer
<12 bpm
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How often should vital signs be checked during a painful procedure?
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q 15 minutes
question
What should be assessed after a procedure involving sedation or analgesia?
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-CV and respiratory function -Arousability -Hydration -Protect from injury
question
What percentage of individuals treated for pain become addicted to opioids?
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<1%
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What percentage of the american population is currently addicted to drugs?
answer
6-15%
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From 1992 to 2001, what happened to the treatment admission rate for opioid addiction?
answer
Doubled
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From 1992 to 2001, that happened to the emergency room visits related to opioid abuse?
answer
Increased by 117%
question
What are the appropriate routes to give opioids to children? which of these should be avoided if possible?
answer
IM IV Oral; avoid IM
question
Should pain medications be given routinely or PRN?
answer
Routinely to manage pain that is expected to last for an extended period of time
question
Should children <18 years old receive intranasal medications?
answer
No
question
Why should rectal administration of drugs be avoided in children, if possible?
answer
Absorption rates vary and kids dislike them
question
Where should painful procedures take place?
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-In treatment room -Away from safe places like bed
question
When should IV medications be given?
answer
For severe pain of sudden onset
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When should oral pain medications be administered?
answer
As soon as the patient can tolerate oral intake
question
Why are oral pain medications preferred?
answer
They have a longer duration of analgesia than parenteral route; decreases peaks and valleys of pain and pain releif
question
What does PRN stand for?
answer
Pro Re Nata (as necessary)
question
What patients are at greatest risk for opioid related respiratory depression?
answer
Smallest
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Which patients should be started on 1/4 to 1/2 of the initial recommendations of pain medication and titrated up as needed?
answer
<6 months <10 kg History of apnea
question
What dosage of medication should a child >50kg receive?
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Adult dosage: DO NOT calculate mg/kg
question
Do opioids have an analgesic ceiling?
answer
No
question
What is the pattern for respiratory depression from opioids?
answer
-Decreased LOC -Decreased depth of respiration -Decreased RR -Decreased O2 sat
question
How long does it typically take oral medications to reach peak analgesic effects?
answer
1-2 hrs
question
What topical medication contains lidocaine and prilocaine in the form of a cream or disk?
answer
ELMA
question
When should ELMA be applied for a superficial procedure such as IV insertion or biopsy?
answer
60 mins before
question
When should ELMA be applied for a deep puncture?
answer
2.5 hrs before
question
What type of dressing should be applied over ELMA?
answer
Occlusive
question
Prior to the procedure, what should the nurse do with ELMA?
answer
Clean the skin and check for adequate response, demonstrate to child that skin is not sensitive by lightly scratching or tapping
question
What indicates an adequate response to ELMA?
answer
Redened, blanched skin
question
What are the advantages of using a PCA?
answer
-Adjusts for individual variation in kinetics and dynamics -Gives a sense of control -Avoids bargain and begging -Safe and effective
question
What are the disadvantages of using a PCA?
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-Expense ($88/day) -Anyone can push the button -Push the button or suffer -May not completely relieve pain -Not a panacea: side effects still persist
question
What is the minimum age for a PCA?
answer
7 years
question
What are the requirements for a PCA?
answer
-Able to push button -Able to quantify pain -Unable to tolerate oral analgesics -Understand the relationship between pushing the button and medication delivery -Understand the safety mechanisms of the machine -Report unsatisfactory pain relief
question
What is the major advantage of using epidural analgesia?
answer
Provides good to excellent analgesia with less side effects than with the use of systemic opioids: -Infrequent nausea -Minimal sedation -Earlier ambulation -Retention of cough reflex -Decreased pulmonary dysfunction -Decreased neuroendocrine and metabolic response to surgical stress
question
What are the disadvantages of epidurals?
answer
-Expense and availability -Parents and caregivers often feel that if the child is not receiving adequate relief of pain from the epidural medication there is noting more that can be done; child and family may not report pain that is not completely relieved -Infrequent use has led to misconceptions and fear with use
question
Epidural use is appropriate for which types of patients?
answer
-Open heart surgery -Abdominal procedures -Anal or urogenital procedures -Orthopedic surgeries of the lower limbs -Thoracic surgeries -Cancer pain -Pancreatitits
question
For which patients is epidural contraindicated?
answer
-Vertebral anomalies that would make catheter placement difficult -Coagulopathies that may make the child at an increased risk for epidural hematomas -Systemic infections
question
If a child receiving an epidural has a temperature spikes, why must the physician be notified?
answer
The epidural catheter in a child with an active systemic infection can be a conduit to the CSF- and a meningitis may result
question
What nonpharmacological measures can be taken to decrease pain?
answer
-Distraction (play, joke, radio, movies, computer games, telling stories) -Relaxation (holding, breathing) -Guided imagery -Positive self talk -Behavioral contracting with rewards -Containment -Nonutritive sucking -Kangaroo care -COmplemetnary and alternative medicine -Massage -Chiropractic options -Heat/cold -Aromatherapy -Hypnosis -TENS units
question
List topical anesthetics appropriate for use with children.
answer
-EMLA -Pain ease (vapocoolant) -Numby stuff -Lidosite -LMX4 -Synera -J tip
question
Explain the gate control theory.
answer
-Inhibitory neuron stimulation reduces pain sensation -Distractions and stimulations can enhance effects of analgesics
question
What position should an infant be held in to give an oral medication?
answer
Semi-reclining
question
What position should a small child be held in to give an oral medication to prevent aspiration?
answer
Upright
question
How should liquid oral medications be administered to children?
answer
In side of mouth in small amounts to allow swallowing
question
If a child does not like the taste of an oral medication, what should the nurse instruct them to do?
answer
Hold their nose
question
What can a nurse do to promote swallowing of oral medication in an infant?
answer
Stroke under chin and hold cheeks together
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