A nurse is caring for an 18-month-old infant who is 12 hr postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?

Poker Chip Tool

Color tool

Numeric scale

FLACC scale

Answer and Explanation

The Correct Answer is D

A. The Poker Chip Tool is used to assess pain in children who can understand the concept of "a few" to "lots" of pain, typically in older children. It is not appropriate for infants or toddlers.

B. The Color tool is used for children who can associate color with pain intensity, but it is generally for older children who can understand this system, not for infants.

C. The Numeric scale is designed for children who are old enough to understand and use numbers (typically older than 8 years). An 18-month-old would not be able to understand this scale.

D. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is specifically designed to assess pain in infants and nonverbal children. It uses behavioral indicators to rate pain intensity and is appropriate for an 18-month-old toddler.

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Correct Answer is B

Explanation

A. Facial edema is not typically associated with a urinary tract infection (UTI). Edema may be seen in other conditions, such as nephrotic syndrome.

B. An increased temperature (fever) is a common manifestation of a UTI. The body responds to the infection with an elevated temperature as part of the immune response.

C. Moist mucus membranes are a sign of adequate hydration and are not specifically related to a UTI.

D. Muscle twitching is not a common sign of a UTI. It could be related to electrolyte imbalances or neurological issues, but it is not typical for UTIs.

A. Changes in height and weight slow down at the onset of adolescence. B. Decisions should be discussed with the parents privately because the adolescent is a minor. C. Adolescents have little interest in discussing health promotion activities. D. The timing of puberty onset affects adolescent self-esteem.

Correct Answer is D

Explanation

A. Growth and changes in height and weight accelerate during adolescence, particularly in the early years, as part of the growth spurt.

B. While it is important to involve parents, adolescent clients should be encouraged to participate in decision-making about their health, as they are developing autonomy. Health decisions should include both the adolescent and the parents when possible.

C. Adolescents are often highly interested in discussing health promotion, particularly topics that are relevant to their peer group, such as body image, sexual health, and mental health.

D. The timing of puberty can significantly impact an adolescent’s self-esteem. Early or late onset of puberty may lead to feelings of self-consciousness or social challenges. Understanding this developmental change is essential in supporting the adolescent’s emotional and psychological well-being.

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A nurse is caring for an 18-month-old infant who is 12 hr postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?

Nursing Test Bank

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