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.
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Related Questions
Correct Answer is D
Explanation
The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.
A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.
The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.
Correct Answer is B
Explanation
b. Platelet count 90,000/mm3.
Explanation:
During pregnancy, it is important to monitor the client's platelet count because a low platelet count can indicate a condition called gestational thrombocytopenia or other potential complications such as preeclampsia or HELLP syndrome. A platelet count of 90,000/mm3 is lower than the normal range and should be reported to the provider for further evaluation and management.
Option a, Hgb 12 g/dL, falls within the normal range for hemoglobin during pregnancy, which is typically between 11-13.5 g/dL. Therefore, it does not require immediate notification to the provider.
Option c, Hematocrit 37%, also falls within the normal range for hematocrit during pregnancy, which is typically between 33-42%. Therefore, it does not require immediate notification to the provider.
Option d, Creatinine 0.7 mg/dL, is within the normal range for creatinine levels and does not indicate any immediate concerns or need for notification to the provider.
It is important to remember that the interpretation of laboratory results should be done in the context of the client's individual clinical presentation and the healthcare provider's assessment. Any concerns or abnormal findings should be communicated to the provider for further evaluation and appropriate management.
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