A nurse is assessing a 12-month-old infant who is immediately postoperative following hernia repair surgery. Which of the following pain measurement tools should the nurse use to determine if the infant is experiencing pain?

FACES

COMFORT

CRIES

FLACC

Answer and Explanation

The Correct Answer is D

A. FACES: The FACES pain scale is a visual analog scale commonly used with older children who can point to or select a facial expression that best represents their pain level. It may not be suitable for infants who may not have the cognitive or motor skills to use the scale effectively.

B. COMFORT: The COMFORT scale assesses pain in infants and young children based on behaviors such as crying, facial expressions, and body movements. It evaluates parameters such as alertness, calmness, respiratory response, physical movement, and muscle tone. The COMFORT scale is suitable for assessing pain in infants and young children, including those who are postoperative.

C. CRIES: The CRIES scale is a neonatal pain assessment tool that evaluates crying, oxygen saturation, vital signs, expression, and sleeplessness. While it is designed for newborns and infants up to 6 months of age, it may not be as appropriate for a 12-month-old infant who is postoperative and beyond the neonatal period.

D. FLACC: The FLACC scale assesses pain in infants and young children based on five behavioral categories: facial expression, leg movement, activity level, cry, and consolability. It is commonly used in pediatric settings and is suitable for assessing pain in infants who are postoperative.

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Correct Answer is C

Explanation

A. Steatorrhea: Steatorrhea refers to the presence of fat in the stool, which can indicate malabsorption or digestive issues, but it is not a typical symptom of a urinary tract infection (UTI). Therefore, it is not relevant to consider steatorrhea in the context of a UTI.

B. Jaundice: Jaundice is characterized by yellowing of the skin and eyes due to elevated levels of bilirubin in the blood. It is typically associated with liver or gallbladder problems and is not a common symptom of a UTI. Therefore, it is not relevant to consider jaundice in the context of a UTI.

C. Incontinence: Incontinence, or the inability to control urination, can be a symptom of a UTI in toddlers. UTIs can cause irritation of the bladder, leading to urgency, frequency, and in some cases, incontinence. Therefore, incontinence is a relevant finding to consider in the context of a UTI.

D. Rebound tenderness: Rebound tenderness is a sign of peritoneal irritation and is typically associated with conditions affecting the abdomen, such as appendicitis or peritonitis. It is not a typical symptom of a UTI. Therefore, it is not relevant to consider rebound tenderness in the context of a UTI.

A. Green zone reading on peak expiratory flow meter B. Rhinitis C. Axillary temperature of 37.2° C (99° F) D. Hacking, nonproductive cough

Correct Answer is D

Explanation

A. Green zone reading on peak expiratory flow meter:

A green zone reading on a peak expiratory flow meter indicates that the child's peak expiratory flow rate (PEFR) is within the normal or stable range. This would not typically be indicative of an exacerbation of asthma. In fact, a green zone reading suggests that asthma is well-controlled.

B. Rhinitis:

Rhinitis, or inflammation of the nasal mucosa, is a common symptom in individuals with asthma, but it is not necessarily indicative of an exacerbation of asthma. Rhinitis can occur due to allergic or non-allergic triggers and may be present even when asthma is well-controlled.

C. Axillary temperature of 37.2°C (99°F):

An axillary temperature of 37.2°C (99°F) is within the normal range for body temperature and is not indicative of an exacerbation of asthma. While fever can occur during exacerbations of asthma, it is not a universal symptom and may be absent in some cases.

D. Hacking, nonproductive cough:

This is the correct option. A hacking, nonproductive cough is a common symptom of asthma exacerbation. During an exacerbation, the airways become inflamed and constricted, leading to coughing. The cough may be dry and unproductive, and it is often worse at night or early in the morning.

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A nurse is assessing a 12-month-old infant who is immediately postoperative following hernia repair surgery. Which of the following pain measurement tools should the nurse use to determine if the infant is experiencing pain?

Nursing Test Bank

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