A nurse is caring for a 5-year-old child who is postoperative following a tonsillectomy.
Which of the following pain scales should the nurse use to determine the child's pain level?
Oucher.
Visual Analog Scale.
FLACC.
FACES.
The Correct Answer is D
Choice A rationale
The Oucher scale uses photographic images or numerical scales and is appropriate for older children who can visually correlate their pain level with the provided scale. It is not ideal for younger children or those unable to understand numerical or photographic representations.
Choice B rationale
The Visual Analog Scale requires a more mature understanding of concepts such as gradients and is suitable for older children and adults. It is not an appropriate tool for a 5-year-old as their cognitive development may limit the accurate use of this scale.
Choice C rationale
The FLACC scale assesses pain based on behavioral observations and is ideal for non-verbal or very young children. However, a 5-year-old can generally articulate their pain or utilize pictorial representations, making other scales more suitable.
Choice D rationale
The FACES scale, featuring cartoonish faces representing varying pain levels, is a validated tool for children as young as 3 years old. Its simplicity and visual clarity make it an effective and age-appropriate method for a 5-year-old to communicate their pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Diaphragms need to be refitted periodically as changes in weight, pregnancy, or aging can affect their fit. This ensures that the device continues to function effectively by providing a proper seal over the cervix, reducing the risk of unintended pregnancy. Therefore, the statement about the diaphragm always being the correct size is inaccurate as it does not consider these physiological factors.
Choice B rationale
Diaphragms are not recommended for use during menstruation because the menstrual flow can compromise their efficacy and hygiene. Additionally, the risk of toxic shock syndrome may increase if the device is used during menstruation. This is a critical point to emphasize for the safe and effective use of diaphragms in contraception.
Choice C rationale
Leaving the diaphragm in place for six hours after intercourse ensures that sperm are effectively trapped and neutralized by the spermicide used with the device. This is essential for preventing fertilization and optimizing contraceptive effectiveness. The timing is critical to allow the spermicide to work while the diaphragm acts as a physical barrier.
Choice D rationale
Leaving the diaphragm in for extended periods beyond six hours is not recommended due to the increased risk of infection and toxic shock syndrome. The device should be removed within a safe timeframe to maintain hygiene and reduce health risks, making the statement about leaving it for a day or two incorrect.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Difficulty feeding in infants can result from fatigue caused by inadequate oxygen delivery to tissues due to heart failure. Feeding is a demanding activity that requires energy and coordination, making it an early symptom of cardiac compromise in pediatric patients.
Choice B rationale
Wheezes or rales are caused by pulmonary congestion or edema, which occur in heart failure due to increased pulmonary venous pressure. This congestion results in fluid accumulation in the alveoli, leading to abnormal breath sounds. These findings require prompt evaluation.
Choice C rationale
Edema in the feet and legs results from systemic venous congestion caused by right-sided heart failure. Increased hydrostatic pressure in peripheral veins leads to fluid leakage into interstitial spaces, causing swelling, especially in dependent areas.
Choice D rationale
Tachypnea occurs as a compensatory mechanism in heart failure. Poor cardiac output reduces oxygen delivery, triggering the respiratory center to increase the breathing rate to improve oxygen uptake and delivery. It is an early sign of cardiopulmonary compromise in children.
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