A nurse is collecting data from an 18-month-old toddler who is postoperative. Which of the following rating scales should the nurse use to identify the toddler's pain level?
Color tool
FACES
Visual analog
FLACC
The Correct Answer is D
Choice A reason:
The color tool is not a pain assessment tool; it is used to assess oxygen saturation levels.
Choice B reason:
The FACES scale is commonly used for children who are 3 years of age and older, but it may not be suitable for an 18-month-old toddler who may have limited ability to express pain through facial expressions.
Choice C reason:
The visual analog scale is typically used for older children and adults. It may not be effective for assessing pain in an 18-month-old toddler.
Choice D reason:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a validated pain assessment tool for young children, including toddlers. It evaluates specific behaviors related to pain, making it suitable for this age group.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Children with attention deficit hyperactivity disorder (ADHD) benefit from frequent breaks in activities. Short, focused periods of activity followed by breaks can help them maintain attention and focus.
Choice B reason:
While providing long-term goals is important for building self-esteem, it may not directly address the child's learning style associated with ADHD.
Choice C reason:
Administering medication at bedtime may not be the most effective timing for managing ADHD symptoms. The timing and dosing of ADHD medications should be discussed with the child's healthcare provider.
Choice D reason:
Children with ADHD benefit from consistent routines rather than constantly changing ones. A predictable routine can help them feel more organized and focused.
Correct Answer is B
Explanation
Choice A reason:
A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.
Choice B reason:
Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.
Choice C reason:
A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require
intervention but not immediate reporting.
Choice D reason:
A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.
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