A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?

Face, legs, activity, cry, consolability (FLACC) scale

Oucher scale

FACES scale

Visual analog scale (VAS)

Answer and Explanation

The Correct Answer is A

A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.

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Correct Answer is A

Explanation

A. Accompany verbal instructions with visual references. Children with ADHD benefit from multimodal teaching strategies. Combining verbal instructions with visual aids helps reinforce understanding and keeps the child focused.
B. Vary the classroom routine to keep the children interested: Children with ADHD thrive on consistency; frequent changes in routine can increase confusion and distractibility.
C. Limit presentation of subjects of interest to the afternoons: This is not evidence-based. Children’s ability to focus varies throughout the day, and important content should not be restricted to a specific time.
D. Increase classroom assignments to stimulate learning: Increasing workload can overwhelm a child with ADHD, leading to frustration and reduced engagement.

A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale." B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10-second interval." D. "I will record the highest reading of the three attempts."

Correct Answer is D

Explanation

A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.

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A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?

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