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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Assessing the erythematous rash is important, as it can indicate the presence of erythema marginatum, a common symptom of rheumatic fever, but it is not the priority.

B. Auscultating the rate and characteristics of the child's heart sounds is the priority assessment because acute rheumatic fever can cause carditis, which affects the heart valves and can lead to serious complications. Early detection of any cardiac involvement is crucial for timely intervention and management.

C. Assessing joint pain is necessary for comfort and symptom management but does not take precedence over potential cardiac complications.

D. Identifying parental anxiety is important for providing emotional support but is not the immediate priority in managing the child's acute condition.

A. Prepare for seizures. B. Expect the skin to turn yellow. C. Encourage progressive activity. D. Prevent dehydration

Correct Answer is D

Explanation

A. Seizures are not a typical complication of polycythemia, though they may occur if the condition progresses to severe levels of blood viscosity.

B. Yellowing of the skin (jaundice) is not associated with polycythemia but with liver conditions.

C. While activity is important, preventing dehydration is more critical in managing polycythemia because dehydration increases blood viscosity, exacerbating the condition.

D. Preventing dehydration is essential as it helps maintain adequate blood flow and reduces the risk of thrombotic events in a child with polycythemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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