A nurse is assessing a 12-month-old infant who is immediately postoperative following hernia repair surgery. Which of the following pain measurement tools should the nurse use to determine if the infant is experiencing pain?
FACES
COMFORT
CRIES
FLACC
The Correct Answer is D
A. FACES: The FACES pain scale is a visual analog scale commonly used with older children who can point to or select a facial expression that best represents their pain level. It may not be suitable for infants who may not have the cognitive or motor skills to use the scale effectively.
B. COMFORT: The COMFORT scale assesses pain in infants and young children based on behaviors such as crying, facial expressions, and body movements. It evaluates parameters such as alertness, calmness, respiratory response, physical movement, and muscle tone. The COMFORT scale is suitable for assessing pain in infants and young children, including those who are postoperative.
C. CRIES: The CRIES scale is a neonatal pain assessment tool that evaluates crying, oxygen saturation, vital signs, expression, and sleeplessness. While it is designed for newborns and infants up to 6 months of age, it may not be as appropriate for a 12-month-old infant who is postoperative and beyond the neonatal period.
D. FLACC: The FLACC scale assesses pain in infants and young children based on five behavioral categories: facial expression, leg movement, activity level, cry, and consolability. It is commonly used in pediatric settings and is suitable for assessing pain in infants who are postoperative.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Decreased respiratory rate: AKI typically does not directly affect respiratory rate. Respiratory rate is more closely related to lung function and oxygenation status rather than kidney function.
B. Polyuria: This is an incorrect option. Polyuria, or increased urine output, is not typically seen in acute kidney injury. In fact, oliguria (decreased urine output) or anuria (absence of urine output) are more common in AKI due to decreased kidney function.
C. Hyperactivity: AKI does not typically cause hyperactivity. In fact, children with AKI may appear lethargic or fatigued due to the buildup of waste products in their bodies and electrolyte imbalances.
D. Edema: This is the correct option. Edema, or swelling due to fluid retention, is a common clinical manifestation of AKI. When the kidneys are unable to adequately filter and excrete excess fluid from the body, fluid accumulates in the tissues, leading to edema. Edema may be particularly noticeable in the face, hands, feet, or around the eyes.
Correct Answer is A
Explanation
A. "What are your reasons for making this decision today?"
This response demonstrates active listening and allows the parent to express their reasons for wanting to discontinue treatment. It opens up a dialogue between the nurse and the parent, which is important for understanding their perspective.
B. "You should discuss your concerns with your child's provider."
While it's important for the parent to communicate with the child's healthcare provider, this response may come across as dismissive of the parent's concerns and decision-making process.
C. "You should give the treatment a chance to work before giving up."
This response may seem judgmental and dismissive of the parent's feelings and autonomy. It does not address the parent's concerns and may further strain the nurse-parent relationship.
D. "Do you need assistance gathering your child's belongings to return home?"
This response is practical but does not address the underlying reasons for the parent's desire to discontinue treatment. It's important for the nurse to engage in therapeutic communication and explore the parent's concerns further.
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