A nurse is caring for a 6-month-old infant who is postoperative. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

FACES

FLACC

Visual Analog Scale

Oucher

Answer and Explanation

The Correct Answer is B

A. FACES. The Wong-Baker FACES scale is used for children aged 3 years and older who can understand and select a face representing their pain level.

B. FLACC. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is used for infants and nonverbal children to assess pain through observation of behaviors.

C. Visual Analog Scale. The Visual Analog Scale (VAS) requires the client to point on a numeric pain scale, which is inappropriate for infants who cannot communicate pain verbally.

D. Oucher. The Oucher scale is similar to FACES and is used in children aged 3–12 years. It relies on self-report, which is not feasible for a 6-month-old infant.

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Correct Answer is D

Explanation

A. Absent. Borborygmus refers to hyperactive bowel sounds, not absent sounds.

B. Blowing sound due to restriction. A blowing sound may indicate a vascular issue, such as a bruit over the aorta, rather than bowel motility.

C. A continuous medium-pitched sound. Medium-pitched sounds may be heard in normal bowel activity, but borborygmus refers to increased, hyperactive sounds.

D. High-pitched, tinkling, rushing, or growling. Borborygmus describes hyperactive bowel sounds, which occur in conditions such as gastroenteritis or hunger.

A. Check the client's toes for color, temperature, and sensation. B. Apply heat to the client's ankle. C. Apply a compression bandage to the client's ankle. D. Encourage range of motion of the client's foot. E. Elevate the client's foot.

Correct Answer is ["A","C","E"]

Explanation

A. Check the client's toes for color, temperature, and sensation: Assesses neurovascular status to detect signs of impaired circulation or nerve injury.

B. Apply heat to the client's ankle: Heat can increase swelling; ice should be used instead (RICE method: Rest, Ice, Compression, Elevation).

C. Apply a compression bandage to the client's ankle: Helps reduce swelling and provides support.

D. Encourage range of motion of the client's foot: Movement may worsen injury if a fracture or soft tissue damage is present.

E. Elevate the client's foot: Reduces swelling by promoting venous return.

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A nurse is caring for a 6-month-old infant who is postoperative. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

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Naxlex Comprehensive Predictor Exams

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