A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level?
Oucher
FLACC
FACES
Visual Analog Scale
The Correct Answer is B
Choice A: The Oucher pain scale is not suitable for a 6-month-old infant, as it is designed for children aged 3 to 13 years who can point to pictures of faces that match their pain level. A 6-month-old infant cannot communicate verbally or point to pictures.
Choice B: The FLACC pain scale is suitable for a 6-month-old infant, as it is designed for infants and children aged 2 months to 7 years who cannot verbalize their pain. The FLACC pain scale assesses five behavioral indicators of pain: face, legs, activity, cry, and consolability. Each indicator is scored from 0 to 2 based on the observation of the nurse. The total score ranges from 0 to 10, with higher scores indicating more pain.
Choice C: The FACES pain scale is not suitable for a 6-month-old infant, as it is designed for children aged 3 years and older who can select a face that matches their pain level. A 6-month-old infant cannot communicate verbally or select a face.
Choice D: The Visual Analog Scale (VAS) is not suitable for a 6-month-old infant, as it is designed for adults and older children who can mark a point on a line that represents their pain level. A 6-month-old infant cannot communicate verbally or mark a point on a line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This instruction is correct, as iron supplements can cause a change in the color and consistency of stools, making them dark, green, or black. This is not a sign of bleeding or infection, but a normal side effect of iron therapy. The parents should be informed of this possibility and reassured that it is harmless.
Choice B: This instruction is incorrect, as iron supplements should not be administered at bedtime, but rather one hour before or two hours after meals. This is because iron absorption is reduced by food, especially dairy products, antacids, or calcium supplements. The parents should be instructed to give the medication on an empty stomach or with a small amount of food if it causes nausea.
Choice C: This instruction is incorrect, as iron supplements should not be given with milk, as milk contains calcium, which can interfere with iron absorption and reduce its effectiveness. The parents should be instructed to avoid giving milk or other dairy products within two hours of the medication.
Choice D: This instruction is incorrect, as iron supplements should not be administered at mealtimes, but rather one hour before or two hours after meals. This is because iron absorption is reduced by food, especially dairy products, antacids, or calcium supplements. The parents should be instructed to give the medication on an empty stomach or with a small amount of food if it causes nausea.

Correct Answer is D
Explanation
Choice A: This action is not appropriate, as it may cause more harm than good to separate the child from the parents without sufficient evidence or reason. Separating the child from the parents can cause fear, anxiety, or resentment in both parties and may interfere with establishing rapport and trust. The nurse should only separate the child from the parents if there is an immediate threat or danger to the child's safety.
Choice B: This action is premature, as it may violate confidentiality and ethical principles to report suspected abuse to the authorities without sufficient evidence or reason. Reporting suspected abuse to the authorities can have serious legal and social consequences for both parties and may escalate or worsen the situation. The nurse should only report suspected abuse to the authorities if there is clear evidence or indication of abuse or if mandated by law.
Choice C: This action is irrelevant, as it may not address the issue or help resolve it to ask a psychiatrist to talk with the parents without sufficient evidence or reason. Asking a psychiatrist to talk with the parents can imply that they have mental health problems or that they are guilty of abuse, which can cause stigma, anger, or denial. The nurse should only ask a psychiatrist to talk with the parents if there is evidence or indication of mental health problems or if requested by them.
Choice D: This action is appropriate, as it can help determine whether there is any evidence or reason to suspect abuse or not. Obtaining a detailed history can provide information about how, when, where, and why the bruises occurred and whether they are consistent with accidental or intentional injury. The nurse should obtain a detailed history from both parties separately and in a nonjudgmental and supportive manner.
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