A nurse is assisting with the care of a 3-month-old infant following a surgical procedure.
Which of the following pain scales should the nurse use to determine the infant’s pain level?
FACES.
Word-Graphic Rating Scale.
FLACC.
Oucher.
The Correct Answer is C
Choice A rationale
The FACES pain scale is typically used for children who are at least 3 years old. It requires the child to compare their pain to a series of faces ranging from smiling to crying.
Choice B rationale
The Word-Graphic Rating Scale is typically used for older children and adolescents who can read and understand the descriptive words associated with each level of pain.
Choice C rationale
The FLACC pain scale, which stands for Face, Legs, Activity, Cry, and Consolability, is appropriate for assessing pain in a 3-month-old infant. It is often used for children under 3 years old or those who are unable to verbally communicate their pain.
Choice D rationale
The Oucher pain scale is typically used for children aged 3 to 13 years. It includes a series of photographs of children’s faces and a numerical scale for older children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Adjusting the harness straps every day is not recommended. The straps should be adjusted only as directed by the healthcare provider or orthopedic specialist to ensure proper positioning and effectiveness of the Pavlik harness.
Choice B rationale
This is the correct answer. Checking the baby’s skin three times a day is important to prevent skin irritation or breakdown under the harness.
Choice C rationale
Massaging lotion on the skin around the harness clasps is not recommended as it can cause skin irritation.
Choice D rationale
The diaper should be placed under the harness to prevent soiling and maintain the effectiveness of the harness.
Correct Answer is C
Explanation
Choice A rationale
While facial paralysis is a serious condition, it is not typically associated with a cleft palate.
Choice B rationale
Ear infections are a common complication of a cleft palate, but they are not typically a sign of an immediate, serious problem.
Choice C rationale
Increased intracranial pressure is not a common complication of a cleft palate, but it is a serious condition that requires immediate medical attention.
Choice D rationale
Drooling is common in children with a cleft palate and is not typically a sign of a serious problem.
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