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 A
Explanation
Choice A: This response indicates an understanding of the teaching, as pancreatic enzymes are essential for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the pancreatic ducts and impair digestion and absorption of nutrients. Pancreatic enzymes help break down fats, proteins, and carbohydrates in food and prevent malnutrition, steatorrhea, or vitamin deficiencies. Pancreatic enzymes should be given with snacks and meals to ensure adequate digestion.
Choice B: This response indicates a lack of understanding of the teaching, as low-fat meals with limited protein are not recommended for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the pancreatic ducts and impair digestion and absorption of nutrients. Low-fat meals with limited protein can cause malnutrition, weight loss, or growth failure in a child who has CF. A high-calorie, high-protein diet is recommended for a child who has CF to meet their increased energy needs and promote growth and development.
Choice C: This response indicates a lack of understanding of the teaching, as limiting fluid intake is not recommended for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the airways and lungs and cause respiratory infections and complications. Limiting fluid intake can cause dehydration, thickening of mucus, or difficulty in expectoration in a child who has CF. Adequate fluid intake is recommended for a child who has CF to hydrate the body, thin out mucus, and facilitate clearance.
Choice D: This response indicates a lack of understanding of the teaching, as restricting salt intake is not recommended for a child who has cystic fibrosis (CF), which is a condition that causes excessive loss of salt through sweat due to abnormal chloride transport in cells. Restricting salt intake can cause hyponatremia, dehydration, or electrolyte imbalance in a child who has CF. Adequate salt intake is recommended for a child who has CF to replace the lost salt and maintain fluid and electrolyte balance.
Correct Answer is D
Explanation
Choice A: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can be used to relieve pain and inflammation in children with influenza. Ibuprofen does not increase the risk of Reye syndrome, which is a rare but serious condition that affects the brain and liver.
Choice B: Grapefruit juice is a citrus fruit that can provide vitamin C and hydration for children with influenza. Grapefruit juice does not increase the risk of Reye syndrome, but it can interact with some medications and affect their absorption or metabolism.
Choice C: A humidifier is a device that adds moisture to the air and can help ease congestion and coughing in children with influenza. A humidifier does not increase the risk of Reye syndrome, but it should be cleaned regularly to prevent bacterial growth and infection.
Choice D: Aspirin is a salicylate that can be used to reduce fever and inflammation in children with influenza. However, aspirin can increase the risk of Reye syndrome, especially in children who have viral infections. Reye syndrome can cause swelling in the brain, liver damage, and even death. Therefore, aspirin should be avoided in children under 19 years old who have influenza or other viral illnesses.
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