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 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.
Correct Answer is C
Explanation
Choice A rationale
While providing age-appropriate stimulation is important for a newborn’s development, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
Choice B rationale
Promoting maternal-infant bonding is important, but it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
Choice C rationale
Maintaining the integrity of the sac is the priority nursing goal for a newborn with a myelomeningocele. The sac contains exposed neural tissue that is at risk for injury and infection. Protecting the sac from damage and keeping it clean and moist until surgery can help prevent complications.
Choice D rationale
While educating the parents about the defect is an important part of nursing care, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
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