A nurse is caring for an 18-month-old infant who is 12 hours postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?
FLACC scale.
Color tool.
Poker Chip Tool.
Numeric scale.
The Correct Answer is A
Choice A rationale:
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is a pain assessment tool commonly used for infants and young children who cannot verbalize their pain. It assesses different behavioral and physiological indicators of pain, such as facial expressions, leg movement, activity level, crying, and response to consoling. Given that the infant is only 18 months old, this scale is appropriate for evaluating their postoperative pain.
Choice B rationale:
The Color tool is not a recognized pain assessment tool. It's essential to use validated and standardized pain assessment scales, and the Color tool does not fit this criterion.
Choice C rationale:
The Poker Chip Tool is not typically used for pain assessment in infants. It's often used with older children to assess pain intensity using a poker chip set that corresponds to different levels of pain. However, for an 18-month-old infant, behavioral assessments like the FLACC scale would be more suitable.
Choice D rationale:
The Numeric scale involves asking the patient to rate their pain on a numerical scale, often from 0 to 10. However, this scale is not appropriate for an 18-month-old infant who is likely unable to comprehend or use numbers to express their pain. The FLACC scale provides a more comprehensive assessment of pain in non-verbal or preverbal children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This statement reflects an accurate understanding of varicella (chickenpox) transmission and infection control. The lesions of varicella contain the virus and are contagious until they have crusted over. Allowing the child to go to the playroom only after the lesions have crusted helps prevent the spread of the virus to other individuals.
Choice B rationale:
This statement is incorrect because waiting for the crusts to fall off the lesions before bathing the child is not necessary. In fact, keeping the lesions clean and maintaining proper hygiene through gentle bathing can help prevent secondary bacterial infections.
Choice C rationale:
This statement is incorrect because bedrest for 3 days is not necessary for a child with varicella. While it's important to minimize contact with others during the contagious phase, physical activity can be gradually resumed as long as the lesions have crusted to prevent transmission.
Choice D rationale:
This statement is incorrect. Once a person has had chickenpox (varicella), they develop immunity to the virus and do not need to wear a mask when visiting someone with active varicella. This is because they are already immune to the virus due to their prior infection.
Correct Answer is C
Explanation
Choice A rationale:
"I should start by feeding my baby 3 tablespoons of solid food." At 6 months of age, infants are typically just beginning to transition to solid foods. Starting with 3 tablespoons of solid food might be overwhelming and inappropriate for the infant's digestive system. Introducing small amounts and gradually increasing the volume allows the infant to adapt to the new textures and flavors.
Choice B rationale:
"I should limit my baby to 8 ounces of juice per day." Juice consumption should be limited for infants. Juice offers little nutritional value and can contribute to excessive calorie intake, leading to potential weight gain and tooth decay. At 6 months, the primary source of nutrition should still be breast milk or formula, and the introduction of solid foods is meant to complement, not replace these sources.
Choice C rationale:
"I should introduce a new solid food to my baby every five to seven days." This statement indicates an understanding of the recommended approach for introducing solid foods to an infant. Introducing a new food every five to seven days allows the parent to monitor for any potential allergic reactions or sensitivities. This gradual approach helps identify specific foods that the infant may not tolerate well.
Choice D rationale:
"I should sweeten my baby's food with a teaspoon of honey." This statement is incorrect and potentially dangerous. Honey should not be given to infants under 12 months of age due to the risk of infant botulism, a serious and potentially fatal illness. Honey can contain spores of Clostridium botulinum bacteria, which can multiply and produce toxins in an infant's immature digestive system. It's important to avoid honey until the child is older to ensure their safety.
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