A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level?
Oucher
FLACC
FACES
Visual Analog Scale
The Correct Answer is B
Choice A: The Oucher pain scale is not suitable for a 6-month-old infant, as it is designed for children aged 3 to 13 years who can point to pictures of faces that match their pain level. A 6-month-old infant cannot communicate verbally or point to pictures.
Choice B: The FLACC pain scale is suitable for a 6-month-old infant, as it is designed for infants and children aged 2 months to 7 years who cannot verbalize their pain. The FLACC pain scale assesses five behavioral indicators of pain: face, legs, activity, cry, and consolability. Each indicator is scored from 0 to 2 based on the observation of the nurse. The total score ranges from 0 to 10, with higher scores indicating more pain.
Choice C: The FACES pain scale is not suitable for a 6-month-old infant, as it is designed for children aged 3 years and older who can select a face that matches their pain level. A 6-month-old infant cannot communicate verbally or select a face.
Choice D: The Visual Analog Scale (VAS) is not suitable for a 6-month-old infant, as it is designed for adults and older children who can mark a point on a line that represents their pain level. A 6-month-old infant cannot communicate verbally or mark a point on a line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because tying colorful latex balloons to the side of
the crib may pose a risk of choking or suffocation for the infant who is in a cast for DDH. Latex balloons are made of rubber that can break easily and form small pieces that can block the airway or lungs if swallowed or inhaled by
the infant. Therefore, avoiding latex products such as balloons, gloves, or bandages is important to prevent accidents or injuries.
Choice B reason: This choice is incorrect because following the doctor's instructions regarding activities and treatment plans is not a specific strategy to promote the infant's growth and development. Following
the doctor's instructions regarding activities and treatment plans is a general responsibility of the nurse that applies to any client who has any condition or procedure. It may help to ensure the safety and effectiveness of the care, but it does not address the developmental needs of the infant who is in a cast for DDH.
Choice C reason: This choice is correct because providing a small electronic toy is a specific strategy to promote
the infant's growth and development. Providing a small electronic toy can help stimulate the infant's senses, cognition, and motor skills by offering visual, auditory, or tactile feedback. It may also help to reduce boredom, frustration, or depression by providing entertainment, diversion, or comfort. Therefore, providing a small electronic toy can help to enhance the developmental outcomes of the infant who is in a cast for DDH.
Choice D reason: This choice is incorrect because changing the infant's diaper as soon as soiling occurs is not a specific strategy to promote the infant's growth and development. Changing the infant's diaper as soon as soiling occurs is a general hygiene measure that applies to any infant who wears a diaper. It may help to prevent skin irritation, infection, or odor by keeping the diaper area clean and dry, but it does not address the developmental needs of the infant who is in a cast for DDH.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect because a regular diet, no added salt may not be sufficient to prevent fluid retention and hypertension in a child who has acute glomerulonephritis. Acute glomerulonephritis is an inflammation of the glomeruli, which are the tiny blood vessels that filter blood in the kidneys. It may cause symptoms such as hematuria, proteinuria, oliguria, edema, or hypertension. Therefore, avoiding salt alone may not reduce sodium and water intake and excretion.
Choice B reason: This choice is incorrect because a low-protein, low-potassium diet may not be necessary for a child who has acute glomerulonephritis. A low-protein, low-potassium diet may be indicated for a child who has chronic kidney disease or end-stage renal disease, which can cause uremia, hyperkalemia, or metabolic acidosis. However, in acute glomerulonephritis, the kidney function usually recovers within weeks or months, and the protein and potassium levels are not significantly affected.
Choice C reason: This choice is incorrect because a low-carbohydrate, low-protein diet may not be appropriate for a child who has acute glomerulonephritis. A low-carbohydrate, low-protein diet may be used for a child who has diabetes mellitus or ketosis-prone epilepsy, which can cause hyperglycemia or ketone production. However, in acute glomerulonephritis, carbohydrate metabolism is not impaired, and the protein intake should be adequate to prevent malnutrition and promote healing.
Choice D reason: This choice is correct because a low-sodium, fluid-restricted diet is an appropriate diet for a child who has acute glomerulonephritis. A low-sodium, fluid-restricted diet helps to reduce the fluid retention and hypertension by limiting the sodium and water intake and excretion. The sodium intake should be less than 2 g per day, and the fluid intake should be equal to the urine output plus 500 mL per day.

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