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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An increased pulse may occur as a response to a variety of factors, including the infection or the administration of the antibiotic, but it does not necessarily indicate a severe allergic reaction.
B. A maculopapular rash could be a mild allergic reaction or side effect to the antibiotic, but it is not as immediately concerning as wheezing, which could indicate an anaphylactic reaction.
C. A headache can be a side effect of antibiotics, but it is not typically an urgent concern unless accompanied by other signs of severe allergic reactions.
D. Wheezing is a critical finding and could indicate an allergic reaction or anaphylaxis, a potentially life-threatening condition. This symptom requires immediate attention and is the priority to report to the provider.
Correct Answer is D
Explanation
A. While prolonged exposure to peanuts may increase the risk of severe reactions, the severity of the allergy doesn't necessarily worsen due to exposure.
B. The child is only allergic to peanuts, not all types of nuts. Therefore, they may be able to safely eat other nuts, but they must avoid peanuts specifically.
C. Many children outgrow certain food allergies, but peanut allergies tend to persist into adulthood, making it less likely that the child will outgrow it by adolescence.
D. Epinephrine is the first-line treatment for a severe allergic reaction, and carrying an epinephrine auto-injector is essential for managing anaphylaxis quickly if it occurs.
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