A client asks a nurse about the normal range for the FLACC Scale and Wong-Baker FACES Pain Rating Scale when assessing their infant’s and older child’s pain respectively.
How should the nurse respond?

Choice A rationale:

The nurse should not state that the FLACC Scale is the best pain assessment tool for all children because pain assessment tools should be age-appropriate.

The FLACC Scale is typically used for infants and young children who cannot effectively communicate their pain verbally.

It assesses facial expression, leg movement, activity, cry, and consolability.

However, it may not be suitable for older children who can use self-reporting pain scales.

Choice B rationale:

This is the correct answer.

The Wong-Baker FACES Pain Rating Scale is designed for children aged 3 years and older.

It uses a series of faces to represent different levels of pain intensity, making it a useful tool for children who may not be able to describe their pain in words.

The scale is widely recognized and accepted for this age group.

Choice C rationale:

The Numeric Rating Scale (NRS) is typically used for older children and adults.

It requires the child to assign a numerical value to their pain, usually on a scale from 0 to 10, with 0 representing no pain and 10 being the worst pain possible.

It may not be the best choice for younger children, especially those under the age of 5, as they may have difficulty using numbers to describe their pain.

Choice D rationale:

The Visual Analog Scale (VAS) is a pain assessment tool that requires a child to mark their pain level on a line, with one end indicating no pain and the other end indicating the worst pain imaginable.

It is often used for older children and adults.

Children aged 8 years and older may be able to use the VAS effectively, but it may not be the best choice for younger children, as it requires the ability to understand and use a visual representation of pain.

Choice A rationale:

I will observe your facial expression.”..

This statement is not appropriate for assessing pain in a non-verbal child using the FLACC Scale because it does not address the five behavioral indicators the scale measures.

The FLACC Scale assesses facial expression, leg movement, activity level, cry, and consolability.

Choice B rationale:

I will watch how you move your legs.”..

This statement is also not appropriate for using the FLACC Scale as it only focuses on one of the five behavioral indicators.

While leg movement is assessed, it's crucial to evaluate all indicators for a comprehensive pain assessment.

Choice C rationale:

I will note your activity level.”..

This statement is partially correct, as the FLACC Scale does assess activity level.

However, it does not cover all the indicators, and it's essential to mention the other components for a complete assessment.

Choice D rationale:

I will listen to your cry and observe your consolability.”..

This statement is the most appropriate choice.

The FLACC Scale rates five behavioral indicators, and this statement acknowledges two of them: cry and consolability.

A comprehensive assessment should include all five indicators for an accurate pain evaluation in non-verbal children.