A nurse is assisting with the care of a 3-month-old infant following a surgical procedure.
Which of the following pain scales should the nurse use to determine the infant’s pain level?
FACES.
Word-Graphic Rating Scale.
FLACC.
Oucher.
The Correct Answer is C
Choice A rationale
The FACES pain scale is typically used for children who are at least 3 years old. It requires the child to compare their pain to a series of faces ranging from smiling to crying.
Choice B rationale
The Word-Graphic Rating Scale is typically used for older children and adolescents who can read and understand the descriptive words associated with each level of pain.
Choice C rationale
The FLACC pain scale, which stands for Face, Legs, Activity, Cry, and Consolability, is appropriate for assessing pain in a 3-month-old infant. It is often used for children under 3 years old or those who are unable to verbally communicate their pain.
Choice D rationale
The Oucher pain scale is typically used for children aged 3 to 13 years. It includes a series of photographs of children’s faces and a numerical scale for older children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Excessive crying is a common symptom of neonatal abstinence syndrome. This is because the baby is experiencing withdrawal symptoms after being exposed to drugs in the womb before birth.
Choice B rationale
Normal sleep patterns are not typically associated with neonatal abstinence syndrome. Infants with this condition often have sleep problems.
Choice C rationale
Decreased muscle tone is not a common symptom of neonatal abstinence syndrome. In fact, these infants often have tight muscle tone and overactive reflexes.
Choice D rationale
Increased appetite is not a typical symptom of neonatal abstinence syndrome. These infants often have poor feeding and sucking, which could lead to poor weight gain.
Correct Answer is A
Explanation
Choice A rationale
Edema in the palm of the hand is a sign of IV infiltration. IV infiltration occurs when IV fluids or medications leak into the surrounding tissues outside the intended vein. This can cause swelling or edema, which is a common sign of infiltration.
Choice B rationale
Absence of blanching at the insertion site is not necessarily an indication of an infiltration. Blanching (whitening of the skin) can occur due to various reasons, including pressure on the site or a reaction to the IV fluid or medication. However, it is not a definitive sign of infiltration.
Choice C rationale
Warmth around the insertion site is not a definitive sign of an infiltration. While warmth can occur due to inflammation or infection, it is not a specific sign of infiltration.
Choice D rationale
Blood in the IV tubing is not a definitive sign of an infiltration. While blood can back up into the IV tubing due to various reasons, including a blocked or kinked catheter, it is not a specific sign of infiltration.
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