A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?
FLACC scale
FACES scale
OUCHER scale
PANAD scale
The Correct Answer is A
A. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who cannot verbally communicate their pain, making it suitable for a 2-month-old.
B. The FACES scale is used for older children who can point to or choose faces that represent their pain level and is not suitable for a 2-month-old.
C. The OUCHER scale is used for children aged 3 to 13 years and includes pictures representing pain, so it is not appropriate for a 2-month-old.
D. The PANAD scale is not a standard pain rating scale used for infants and is less commonly used than the FLACC scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Projectile vomiting is a classic sign of pyloric stenosis due to the obstruction of the pylorus, which prevents normal stomach emptying.
B. A ridged abdomen is not specific to pyloric stenosis; it may indicate other abdominal issues.
C. Red currant jelly stools are associated with intussusception, not pyloric stenosis.
D. Distended neck veins are typically associated with right-sided heart failure or fluid overload, not pyloric stenosis.
Correct Answer is D
Explanation
A. The conjunctivae can show signs of cyanosis but is not the most reliable indicator of central cyanosis.
B. Ear lobes may show peripheral cyanosis but are not reliable for central cyanosis.
C. The soles of the feet are not typically assessed for cyanosis in this context.
D. The oral mucosa is the most reliable indicator of central cyanosis, as it reflects the oxygenation status of the blood more accurately.
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