A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?

Face, legs, activity, cry, consolability (FLACC) scale

Oucher scale

FACES scale

Visual analog scale (VAS)

Answer and Explanation

The Correct Answer is A

A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.

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Correct Answer is ["B","C","D","F"]

Explanation

Findings that require follow-up:

Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.

A. Protective environment B. Airborne C. Contact D. Droplet

Correct Answer is D

Explanation

A. Protective environment: This is for immunocompromised clients, not infectious diseases like pertussis.
B. Airborne: Airborne precautions are used for diseases like tuberculosis, measles, or varicella, which spread through smaller airborne particles.
C. Contact: Contact precautions are for diseases transmitted via direct contact, such as MRSA or C. difficile, and are not appropriate for pertussis.
D. Droplet. Pertussis is transmitted through respiratory droplets, so droplet precautions (e.g., wearing a surgical mask and maintaining distance) are essential to prevent the spread.

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A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","F"]

Explanation

A nurse is admitting a child who has pertussis. Which of the following isolation precautions should the nurse initiate for the child?

Correct Answer is D

Explanation

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