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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale:
Headache is an expected finding in a school-age child with bacterial meningitis. Bacterial meningitis is an inflammation of the meninges, and the membranes surrounding the brain and spinal cord, often caused by bacteria. The inflammatory process can lead to increased intracranial pressure, which commonly presents as a headache. This headache is often severe and can be accompanied by other symptoms like fever, irritability, and sensitivity to light.
Choice B rationale:
A negative Kernig sign is a possible finding in a school-age child with bacterial meningitis. Kernig sign is a clinical test performed to assess for meningitis. A positive Kernig sign is characterized by resistance and pain in extending the knee when the hip is flexed at a 90-degree angle. However, a negative Kernig sign does not rule out meningitis, as it might not always be present.
Choice C rationale:
Vomiting is an expected finding in a school-age child with bacterial meningitis. The increase in intracranial pressure due to inflammation of the meninges can lead to nausea and vomiting. The vomiting is often projectile and may not be relieved by eating or drinking.
Choice D rationale:
Seizures are an expected finding in a school-age child with bacterial meningitis. The inflammation of the brain and meninges can irritate the brain tissue and trigger seizures. Seizures in the context of bacterial meningitis might be generalized or focal in nature.
Choice E rationale:
Tinnitus (ringing in the ears) is not a typical finding associated with bacterial meningitis. The main symptoms of bacterial meningitis are related to the central nervous system and meningeal irritation, such as headache, fever, neck stiffness, and neurological changes. Tinnitus is not a common manifestation of bacterial meningitis and is not part of the typical clinical picture.

A. A 34-month-old child who has several small bruises on the shins. B. A 6-year-old child who has a fracture of the arm from a bicycle injury. C. A 15-month-old child who bites other children while at daycare. D. A 4-year-old child who has a history of frequent urinary tract infections.

Correct Answer is D

Explanation

A history of frequent urinary tract infections (UTIs) is a sign of child maltreatment. It may indicate sexual abuse, which can introduce bacteria into the urinary tract.Sexual abuse may also cause genital or anal trauma, sexually transmitted infections, or pregnancy 1. UTIs are uncommon in children, especially in boys.The normal frequency of UTIs in children is around 1 in 10 girls and 1 in 30 boys by the age of 16 years

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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?

Nursing Test Bank

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