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. Press the skin over the client's ankle bone. Skin over the bony prominences is not ideal for assessing turgor, as it may not accurately reflect dehydration.

B. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. This describes petechiae, which is a sign of bleeding disorders, not hydration status.

C. Lightly palpate the skin using the fingertips. Palpation does not assess elasticity.

D. Grasp a fold of skin on the client's forearm or near the sternum. The best way to check for dehydration is by pinching the skin on the sternum or forearm and observing how quickly it returns to normal.

A. 4+ B. 3+ C. 2+ D. 1+

Correct Answer is B

Explanation

A. 4+: 4+ pitting edema corresponds to an indentation of 8 mm or more, which is more severe than the 6 mm described in the question.

B. 3+: 3+ pitting edema is characterized by an indentation of 6 mm and indicates moderately severe fluid retention.

C. 2+: 2+ pitting edema corresponds to an indentation of 4 mm, which is less than the 6 mm described.

D. 1+: 1+ pitting edema corresponds to an indentation of 2 mm, which is mild and does not match the severity in the scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

Correct Answer is B

Explanation

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