A nurse is caring for a 4-year-old child who underwent surgery. The child is unable to verbalize pain reliably. Which pain assessment tool is most appropriate?

Visual Analog Scale

FLACC scale

Faces Pain Scale

Numeric Rating Scale

Answer and Explanation

The Correct Answer is B

A. Visual Analog Scale (VAS) is incorrect because it requires the child to understand and mark a point on a line to represent pain intensity, which is often too complex for a 4-year-old, especially if they cannot verbalize pain reliably.

B. FLACC scale is correct. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is an observational tool designed for children who cannot self-report pain. It assesses behavioral and physiological indicators of pain including facial expression, leg movement, activity level, crying, and consolability. Scores range from 0 to 10, allowing for objective assessment and monitoring of pain in young children, infants, or nonverbal patients.

C. Faces Pain Scale is incorrect because it relies on the child’s ability to understand and point to a facial expression that represents their pain. While appropriate for some preschoolers, a 4-year-old who cannot reliably verbalize or comprehend the scale may not use it accurately.

D. Numeric Rating Scale is incorrect because it requires the child to assign a number (0–10) to describe pain, which is generally suitable for children aged 7 and older who can understand abstract numerical concepts.

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Correct Answer is D

Explanation

A. Encouraging the child to drink fluids to stay hydrated is incorrect because while hydration is important, the priority is identifying and managing potential increased intracranial pressure (ICP). Giving fluids before assessing neurological status may delay recognition of a serious complication.

B. Positioning the child in a flat supine position is incorrect because a flat supine position can actually increase ICP. Postoperative positioning for brain surgery typically involves head elevation (30 degrees) to promote venous drainage and reduce ICP, unless contraindicated.

C. Administering an antiemetic to control vomiting is incorrect as controlling vomiting is secondary. Vomiting can be a sign of increased ICP, so addressing the underlying cause is more important than treating symptoms alone.

D. Assessing the child's neurological status and checking for signs of increased intracranial pressure is correct. Vomiting and headache after brain surgery are red flags for increased ICP, which can lead to life-threatening complications such as brain herniation. Priority nursing actions include frequent neurological assessments (level of consciousness, pupil size and reactivity, motor function), monitoring vital signs for changes in blood pressure, pulse, and respiration (Cushing’s triad), notifying the healthcare provider immediately if ICP is suspected, and implementing interventions to reduce ICP, such as proper positioning, oxygenation, and minimizing stimuli.

A. Teaching the family about long-term management of asthma B. Avoiding using any latex product C. Administering medication for long-term desensitization D. Using only nonallergenic latex products

Correct Answer is B

Explanation

A. Teaching the family about long-term management of asthma is incorrect because asthma management is not directly related to latex allergy, although children with latex allergy may have an increased risk of atopy. The focus should be on latex avoidance.

B. Avoiding using any latex product is correct. Children with spina bifida are at high risk for latex allergy due to frequent surgical procedures and exposure to latex-containing medical products. Complete avoidance of latex in medical equipment, gloves, toys, and household items is the most important preventive intervention to reduce the risk of anaphylaxis or allergic reactions.

C. Administering medication for long-term desensitization is incorrect because there is currently no safe or standard desensitization therapy for latex allergy. Management focuses on prevention and avoidance.

D. Using only nonallergenic latex products is partially misleading. There is no guarantee that “nonallergenic” latex products are completely safe; therefore, latex-free alternatives should be used instead of relying on “nonallergenic” labels.

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A nurse is caring for a 4-year-old child who underwent surgery. The child is unable to verbalize pain reliably. Which pain assessment tool is most appropriate?

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Explanation

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