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 A

Explanation

A. "How do you handle stress?" While stress may influence some skin conditions (e.g., psoriasis, eczema), this question is not directly related to a focused skin assessment and may be too vague or irrelevant.

B. "Does your skin condition keep you awake at night?" Skin conditions such as eczema or urticaria can cause pruritus, leading to sleep disturbances. This is a relevant question.

C. "How does your skin condition make you feel about yourself?" Skin conditions can affect body image and self-esteem, making this an important question for psychosocial assessment.

D. "Have you had any changes in your diet?" Certain food allergies or deficiencies can trigger dermatologic conditions (e.g., celiac disease, atopic dermatitis), making this question appropriate.

A. 5th Intercostal Space, Midclavicular Line B. 2nd Intercostal Space, Left Sternal Border C. 2nd Intercostal Space, Right Sternal Border D. 3rd Intercostal Space, Left Sternal Border

Correct Answer is C

Explanation

A. 5th Intercostal Space, Midclavicular Line. This is the location for the apical pulse (PMI) at the mitral area, not the aortic valve.

B. 2nd Intercostal Space, Left Sternal Border. This is the location of the pulmonic valve, not the aortic valve.

C. 2nd Intercostal Space, Right Sternal Border. The aortic valve is best auscultated at the right second intercostal space, next to the sternum.

D. 3rd Intercostal Space, Left Sternal Border. This is the Erb’s point, which provides equal S1 and S2 sounds, but it is not the best location for auscultating aortic valve dysfunction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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