A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair.
Which of the following pain rating tools should the nurse use?
FACES Scale
FLACC Scale
Color tool
Numeric scale
The Correct Answer is B
b. FLACC Scale.
Explanation: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is a pain assessment tool commonly used for infants and young children who are unable to self-report their pain. It assesses five categories of behavior: facial expression, leg movement, activity level, cry, and consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the specific scale used. The scores are then totaled to provide an overall pain assessment.
The FACES Scale, also known as the Wong-Baker FACES Pain Rating Scale, is a tool commonly used for children who can understand and self-report their pain. It consists of a series of faces with different expressions representing varying degrees of pain.
The Color tool is not a recognized pain rating tool. It may refer to an assessment of skin color, which can be used to assess oxygenation or circulation but not specifically for pain.
The Numeric scale is a pain rating tool that involves asking the individual to rate their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. However, this scale may not be suitable for a 3-month-old infant who is unable to comprehend numbers or communicate effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should recommend that the client who has diminished breath sounds and paradoxical chest movement receive care first. This client is likely experiencing a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.
Option a is incorrect because a client who has a head injury and whose pupils are fixed and dilated may have experienced brain death and may not be able to be resuscitated.
Option b is incorrect because a dislocated shoulder, while painful, is not immediately life-threatening. Option c is incorrect because a scalp laceration with intermittent bleeding can be managed with pressure and is not immediately life-threatening.
Correct Answer is A
No explanation
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