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: This statement does not indicate a need for further teaching, as it is correct that insulin can be injected anywhere there is adipose tissue. Adipose tissue is the layer of fat under the skin that can absorb insulin and prevent damage to muscles or organs. The common sites for insulin injection are the abdomen, thighs, buttocks, or upper arms.
Choice B: This statement does not indicate a need for further teaching, as it is correct that the child should rotate sites after 5 injections in one area. Rotating sites can prevent lipodystrophy, which is a condition that causes abnormal changes in fat tissue due to repeated injections. Lipodystrophy can affect the appearance and absorption of insulin in the affected area.
Choice C: This statement indicates a need for further teaching, as it is incorrect that the child should aspirate before injecting the insulin. Aspiration is the process of pulling back on the plunger of the syringe to check for blood before injecting the medication. Aspiration is not recommended for insulin injection, as it can cause pain, bruising, or leakage of insulin from the injection site.
Choice D: This statement does not indicate a need for further teaching, as it is correct that insulin should be injected at a 90-degree angle. Injecting insulin at a 90-degree angle can ensure that the medication reaches the adipose tissue and prevents skin irritation or muscle damage. The only exception is if the child has very thin skin or uses very short needles, in which case they may inject at a 45-degree angle.
Correct Answer is C
Explanation
Choice A: A popping sensation when swallowing is not a sign of a tympanic membrane rupture, as it is a normal phenomenon that occurs when the eustachian tube opens and closes to equalize the pressure between the middle ear and the atmosphere. A popping sensation when swallowing may be associated with otitis media with effusion, which is a condition that causes fluid accumulation behind the eardrum, but it does not indicate a rupture.
Choice B: Green-blue discharge could be indicative of infection but is not as directly related to the rupture event as the sudden pain relief is.
Choice C: The correct answer is sudden relief of pain. This is because the rupture of the tympanic membrane releases the pressure and fluid that has built up in the middle ear, leading to an immediate decrease in pain.
Choice D: An increased temperature is not a sign of a tympanic membrane rupture, as it is a nonspecific symptom that may indicate various conditions, such as inflammation, infection, or fever. An increased temperature may be associated with otitis media with effusion, which is a condition that causes fluid accumulation behind the eardrum, but it does not indicate a rupture.
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