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. Paralytic ileus. A postoperative complication in which the intestines stop moving due to anesthesia or surgical trauma. Absence of bowel sounds, abdominal distention, and no flatus are key signs.

B. Incisional infection. An incisional infection would present with redness, warmth, drainage, and fever, but not absence of bowel sounds.

C. Fecal impaction. Fecal impaction causes stool retention, and the client might still pass small amounts of liquid stool, whereas paralytic ileus presents with no bowel movement at all.

D. Health care-associated Clostridium difficile. C. difficile infection presents with frequent watery diarrhea, not absent bowel sounds.

A. The client takes a 20-min nap each afternoon. B. The client has gained 4.5 kg (10 lb) in the past month. C. The client takes a walk for 1 hr each day. D. The client is taking a poetry class.

Correct Answer is B

Explanation

A. The client takes a 20-min nap each afternoon. Taking a short nap is a healthy coping mechanism and does not indicate ineffective coping.

B. The client has gained 4.5 kg (10 lb) in the past month. Sudden weight gain can indicate emotional eating or stress-related metabolic changes, which are signs of ineffective coping.

C. The client takes a walk for 1 hr each day. Walking is a positive coping strategy that helps manage stress.

D. The client is taking a poetry class. Engaging in creative activities is a healthy coping mechanism that can reduce stress.

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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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Explanation

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Correct Answer is B

Explanation

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