Exhibits
The nurse determines the client is in pain.
Which pain scales would be appropriate for this client? Select all that apply.
FLACC Postoperative Pain Scale
Riley Infant Pain Scale
Poker Chip Tool
Visual Analog Scale
Numeric
FACES
Correct Answer : A,B
A. FLACC Postoperative Pain Scale: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is commonly used for infants and young children who cannot verbally report their pain. It assesses behavioral cues such as facial expressions, leg movement, activity level, crying, and ability to be consoled, making it appropriate for this 4-month-old infant.
B. Riley Infant Pain Scale: This scale is specifically designed for infants under 1 year of age. It evaluates facial expression, sleep patterns, movements, crying, and verbal cues to determine the level of discomfort. Since this infant is postoperative and unable to self-report pain, this scale is a useful tool.
C. Poker Chip Tool: This tool is used for older children, typically 4 years and above, who can understand the concept of counting and associating poker chips with pain intensity. It is not appropriate for a 4-month-old infant who lacks the cognitive ability to use symbolic representation.
D. Visual Analog Scale: This scale requires the client to mark pain intensity on a continuous line, making it appropriate only for older children (around 7 years and older) who understand abstract concepts. A 4-month-old infant cannot comprehend or use this scale.
E. Numeric: The numeric pain scale (0–10) is used for older children and adults who can assign a number to their pain. Infants and young children cannot use this scale, making it inappropriate for this client.
F. FACES: The Wong-Baker FACES Pain Rating Scale is designed for children 3 years and older who can recognize and correlate facial expressions with pain levels. A 4-month-old does not have the cognitive ability to use this scale reliably.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Arched back. An arched back can be seen in conditions such as gastroesophageal reflux disease (GERD) or neurological disorders but is not a hallmark feature of the condition described. The presence of an olive-like mass and hunger despite vomiting suggests a different diagnosis.
B. Coffee-ground emesis. Coffee-ground emesis indicates the presence of digested blood, often seen in gastrointestinal bleeding. This is not a typical finding in infants with the described symptoms, which are more consistent with pyloric stenosis.
C. Projectile vomiting. The combination of dehydration, extreme hunger, and a palpable olive-like mass in the right upper abdomen is classic for hypertrophic pyloric stenosis. This condition causes progressive gastric outlet obstruction, leading to non-bilious, projectile vomiting after feeds. Vomiting occurs because food cannot pass through the thickened pyloric sphincter.
D. Frequent pauses. Frequent pauses during feeding may be observed in conditions such as respiratory distress or neuromuscular disorders, but they are not characteristic of pyloric stenosis. Infants with pyloric stenosis often appear eager to feed but vomit forcefully due to gastric outlet obstruction.
Correct Answer is ["25"]
Explanation
Calculate the total daily dose:
Total daily dose (mg) = Weight (kg) x Dosage (mg/kg/day)
= 25 kg x 10 mg/kg/day
= 250 mg/day
Calculate the volume to administer per dose:
Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)
Available concentration = 50 mg / 5 mL
= 10 mg/mL
Volume to administer (mL) = 250 mg / 10 mg/mL
= 25 mL
The nurse should administer 25 mL per dose.
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