A nurse is caring for a 9-year-old client who is immediately postoperative. The client is nonverbal and has both cognitive and developmental delays. Which of the following pain scales should the nurse use to evaluate the client's pain?
FACES Scale.
Numerical scale.
FLACC pain assessment scale.
Visual analog scale.
The Correct Answer is C
Choice A reason:
The FACES Scale is a visual pain scale typically used for children who can understand and verbalize their pain intensity. It consists of a series of faces with varying expressions, from smiling to crying, to help the child express their pain level. However, since the client in question is nonverbal and has cognitive and developmental delays, this scale may not be suitable as they might not be able to communicate using this tool effectively.
Choice B reason:
The Numerical Scale involves asking the patient to rate their pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. While this scale is commonly used for older children and adults, it may not be appropriate for a nonverbal and developmentally delayed 9-year-old client, as they may not understand or be able to use numbers effectively to express their pain.
Choice C reason:
The FLACC pain assessment scale is designed for nonverbal or preverbal individuals, including children and those with cognitive impairments. FLACC stands for Face, Legs, Activity, Cry, and Consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the version used, based on specific observed behaviors. The scores are then totaled to give an overall pain assessment. This scale is particularly suitable for the current client's condition as it focuses on observable behaviors rather than verbal communication.
Choice D reason:
The Visual Analog Scale (VAS) requires the patient to mark a point along a line that represents their pain intensity, with one end indicating no pain and the other end indicating the worst pain. Although this scale is useful for older children and adults, it may not be appropriate for a 9-year-old client with cognitive and developmental delays who might not fully comprehend the concept of the scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
The WBC count of 10,000/mm is within the normal range, indicating a normal white blood cell count. There is no cause for concern, and the nurse does not need to report this result to the provider.
Choice B reason:
The Hgb level of 6.8 g/dL is significantly below the normal range, which indicates severe anemia. Menorrhagia, or heavy menstrual bleeding, could be a potential cause of this low hemoglobin level. Anemia can lead to various complications, including fatigue, weakness, and decreased oxygen delivery to tissues. This result requires immediate attention, and the nurse should promptly report it to the healthcare provider for further evaluation and management.
Choice C reason:
The Creatinine level of 0.8 mg/dL is within the normal range. Creatinine is a marker of kidney function, and a normal value suggests that the kidneys are functioning adequately. Since the result is normal, the nurse does not need to report this to the provider.
Choice D reason:
The Potassium level of 3.5 mEq/L is within the normal range, indicating a normal potassium level. There is no immediate concern with this result, and the nurse does not need to report it to the provider.
Correct Answer is D
Explanation
Choice A reason:
Brown in color. The rationale for this choice is that a partial-thickness burn involves damage to the epidermis and the dermis but not the full thickness of the skin. It typically presents with redness, swelling, and blisters. While the burned area may have some discoloration, it is more likely to be red or pink rather than brown. Brown coloration would suggest a deeper burn involving the full thickness of the skin and potentially underlying structures.
Choice B reason:
Leathery appearance. This choice is not expected in a partial-thickness burn. A leathery appearance is characteristic of a full-thickness (third-degree) burn, which involves the destruction of the epidermis, dermis, and potentially deeper tissues. In a partial-thickness burn, the skin may appear red, swollen, and blistered, but it should not have a leathery texture.
Choice C reason:
Visible ligaments. This choice is not indicative of a partial-thickness burn either. Partial- thickness burns primarily affect the epidermis and dermis, but they do not extend deep enough to expose ligaments or other structures below the skin. Visible ligaments would suggest a full-thickness burn or an injury that extends beyond the skin layers.
Choice D reason:
Blister formation. This is the correct choice. Blister formation is a common clinical manifestation of a partial-thickness burn. The injury causes fluid accumulation between the layers of the skin (epidermis and dermis), leading to the formation of blisters. The blisters may be filled with clear fluid and are usually painful and sensitive to touch.
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