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?

Choice A: Loosening restrictive clothing is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. A tonic-clonic seizure is a type of seizure that involves the stiffening of muscles (tonic phase) followed by jerking movements (clonic phase). Loosening restrictive clothing can prevent injury or discomfort to the child during or after the seizure.

Choice B: Placing a pillow under the child's head is not the priority action, but rather an inappropriate action for a child who is having a tonic-clonic seizure and vomiting. A pillow under the head can obstruct the airway or cause aspiration of vomitus into the lungs. The nurse should remove any pillows or objects from around the head and neck area and support the head with their hands or on a flat surface.

Choice C: Clearing the area of hazards is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. Clearing the area of hazards can prevent injury or harm to the child or others during or after the seizure. The nurse should remove any sharp, hard, or flammable objects from near or under the child and move any furniture or equipment away.

Choice D: Positioning the child side-lying is the priority action for a child who is having a tonic-clonic seizure and vomiting, as it can protect the airway and prevent aspiration of vomitus into the lungs. Aspiration can cause pneumonia, which is an infection of the lungs that can cause fever, cough, difficulty breathing, or death. The nurse should turn the child's head to one side and place them on their side with their knees bent and one arm under their head. The nurse should also suction any vomitus from their mouth and nose if needed.

Choice A reason: This choice is incorrect because the loss of a parent is not the priority risk factor for suicide completion. Loss of a parent is a stressful life event that may cause grief, depression, or anxiety in an adolescent, but it does not necessarily increase the risk of suicide completion. However, the loss of a parent may be associated with other risk factors such as low self-esteem, poor coping skills, or social isolation, which can contribute to suicidal ideation or behavior.
Choice B reason: This choice is incorrect because a history of substance abuse is not the priority risk factor for suicide completion. History of substance abuse is a behavioral problem that may impair the judgment, mood, or impulse control of an adolescent, but it does not necessarily increase the risk of suicide completion. However, a history of substance abuse may be associated with other risk factors such as mental illness, family conflict, or legal trouble, which can contribute to suicidal ideation or behavior.
Choice C reason: This choice is correct because a previous suicide attempt is the priority risk factor for suicide completion. Previous suicide attempt is a clear indicator of suicidal intent and capability, and it increases the likelihood of future attempts and completion. According to the American Foundation for Suicide Prevention (AFSP), about 40% of people who die by suicide have a history of previous attempts. Therefore, assessing and addressing previous suicide attempts is essential to prevent further harm and save lives.
Choice D reason: This choice is incorrect because active psychiatric disorder is not the priority risk factor for suicide completion. Active psychiatric disorder is a mental health condition that may affect the thoughts, feelings, or behaviors of an adolescent, but it does not necessarily increase the risk of suicide completion. However, active psychiatric disorder may be associated with other risk factors such as hopelessness, helplessness, or isolation, which can contribute to suicidal ideation or behavior.