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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:

Diminished pulses can be indicative of decreased cardiac output, as it suggests that there may be a reduction in the volume of blood being pumped by the heart.

Choice B reason:

Extremities warm to touch is not necessarily indicative of decreased cardiac output. It may be related to other factors, such as ambient temperature or local blood flow.

Choice C reason:

Capillary refill of 2 seconds is within the normal range for a preschooler, and it is not a strong indicator of decreased cardiac output.

Choice D reason:

A blood pressure of 112/66 mm Hg is within the normal range for a preschooler and is not a strong indicator of decreased cardiac output.

A. Increased urinary output B. Tachycardia C. Bounding peripheral pulses D. Increased blood pressure

Correct Answer is B

Explanation

Choice A reason:

Increased urinary output is not typically associated with heart failure. In fact, heart failure often leads to decreased urine output due to decreased cardiac output.

Choice B reason:

Tachycardia (rapid heart rate) is a common manifestation of heart failure in infants. The heart compensates for decreased cardiac output by beating faster.

Choice C reason:

Bounding peripheral pulses are not typically associated with heart failure. In fact, weak peripheral pulses may be a sign of decreased cardiac output.

Choice D reason:

Increased blood pressure is not typically associated with heart failure in infants. Instead, infants with heart failure may have low or normal blood pressure.

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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?

Nursing Test Bank

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