A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?
A 10-year-old client who had an appendectomy
A 3-year-old toddler who has a broken elbow
A 4-year-old preschooler who had a tonsillectomy
A 4-day-old infant who had a repair of a birth defect
A 4-day-old infant who had a repair of a birth defect
The Correct Answer is D
Choice A reason: The CRIES pain scale is not suitable for a 10-year-old as this scale is designed for neonates, typically those who are 0 to 6 months old.
Choice B reason: A 3-year-old toddler would be better assessed with a pain scale that allows for their level of understanding and communication, such as the Faces Pain Scale-Revised.
Choice C reason: A 4-year-old preschooler can typically communicate their pain verbally or by using a faces pain scale, making the CRIES scale less appropriate.
Choice D reason: The CRIES pain scale is specifically designed for neonates and is appropriate for assessing pain in a 4-day-old infant who cannot verbally communicate their pain.
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Correct Answer is D
Explanation
Choice A reason: The FACES pain scale is commonly used for children who are able to select a face that best describes their pain. However, this scale is not suitable for a 6-month-old infant post-myringotomy, as infants of this age cannot verbally communicate or reliably choose a face to represent their pain level.
Choice B reason: The Visual Analog Scale (VAS) is typically used for older children and adults who can understand and indicate their level of pain by marking a point on a line. This scale is not appropriate for infants due to their developmental stage and inability to communicate or understand the concept of the scale.
Choice C reason: The Oucher pain scale includes both a photographic scale with pictures of children's faces showing different levels of pain and a numerical scale. While it is designed for children aged 3 to 12 years, it is not suitable for infants, as they cannot verbally express their pain or point to a photograph to indicate their pain level.
Choice D reason: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is an appropriate choice for assessing pain in infants and young children who are non-verbal. It involves observing specific behaviors and assigning a score from 0 to 2 for each category, resulting in a total score between 0 and 10. This observational tool allows healthcare providers to assess pain levels based on the infant's behavior and physiological responses.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Placing a client with active pulmonary TB in a room with positive airflow is not recommended, as positive airflow would push potentially contaminated air into general circulation, risking the spread of TB. Instead, a room with negative airflow is appropriate to contain and remove contaminated air.
Choice B reason: Determining whether the client lives alone or with others is important for public health and contact tracing purposes. If the client lives with others, those individuals may need to be tested and monitored for TB as well.
Choice C reason: Using an alcohol-based hand cleaner is a standard practice unless hands are visibly soiled. If hands are visibly soiled, handwashing with soap and water is necessary.
Choice D reason: Reminding the client to cover their mouth with a tissue when coughing is a key measure to prevent the spread of TB, which is transmitted through airborne particles from coughs or sneezes.
Choice E reason: Antifungal medications are not used to treat TB, which is caused by a bacterium, not a fungus. The client should be instructed about taking anti-tuberculosis medications, not antifungals.
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