A nurse is caring for a 6-month-old infant who is postoperative. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

FACES

FLACC

Visual Analog Scale

Oucher

Answer and Explanation

The Correct Answer is B

A. FACES. The Wong-Baker FACES scale is used for children aged 3 years and older who can understand and select a face representing their pain level.

B. FLACC. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is used for infants and nonverbal children to assess pain through observation of behaviors.

C. Visual Analog Scale. The Visual Analog Scale (VAS) requires the client to point on a numeric pain scale, which is inappropriate for infants who cannot communicate pain verbally.

D. Oucher. The Oucher scale is similar to FACES and is used in children aged 3–12 years. It relies on self-report, which is not feasible for a 6-month-old infant.

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Correct Answer is D

Explanation

A. Bruising that covers the arms and legs. While elderly clients may bruise easily due to fragile blood vessels, widespread bruising suggests coagulopathy, trauma, or abuse, not normal aging.

B. Velvety texture or a gray frosty covering. Velvety skin can indicate endocrine disorders (e.g., acanthosis nigricans), and a gray frost-like appearance suggests uremia (kidney failure), which is not part of normal aging.

C. Large, raised patches that measure greater than 6mm. Skin lesions greater than 6mm should be evaluated for malignancy (e.g., melanoma, seborrheic keratosis).

D. Thin skin with little subcutaneous fat. Aging causes loss of collagen and subcutaneous fat, making the skin thin, fragile, and prone to injury.

A. Apply cornstarch to keep the skin dry. B. Reposition the client every 3 hr. C. Massage bony prominences to promote circulation. D. Provide the client with a diet high in protein.

Correct Answer is D

Explanation

A. Apply cornstarch to keep the skin dry. Cornstarch can cause skin irritation or promote bacterial/fungal growth, which increases the risk of breakdown rather than preventing it.

B. Reposition the client every 3 hr. Clients at risk for skin breakdown should be repositioned at least every 2 hours to relieve pressure and prevent pressure ulcers.

C. Massage bony prominences to promote circulation. Massaging bony prominences can cause tissue damage and increase the risk of pressure ulcers instead of preventing them.

D. Provide the client with a diet high in protein. Protein is essential for skin repair and maintenance, helping prevent breakdown and promote healing.

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A nurse is caring for a 6-month-old infant who is postoperative. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

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