A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

Choice A reason: Restlessness can be a sign of discomfort or pain, especially in a postoperative client. It may manifest as constant shifting or an inability to remain still, indicating that the client is trying to find a position that alleviates the pain.

Choice B reason: Clenching, such as tightly gripping the handrails of the bed or making fists, can indicate that the client is trying to manage pain or discomfort through tension in the muscles.

Choice C reason: Grimacing, or making a pained facial expression, is a clear nonverbal cue of pain. It often involves furrowing the brow, closing the eyes tightly, or contorting the mouth.

Choice D reason: Drowsiness is not typically a direct indicator of pain. It may be related to medication effects, fatigue, or the body's response to healing post-surgery. However, it does not specifically signal pain.

Choice E reason: Moaning, groaning, or making other vocal sounds can be a response to pain, particularly in clients who are unable to articulate their pain verbally due to sedation or other factors.

Choice A reason: The FACES pain scale is commonly used for children who are able to select a face that best describes their pain. However, this scale is not suitable for a 6-month-old infant post-myringotomy, as infants of this age cannot verbally communicate or reliably choose a face to represent their pain level.

Choice B reason: The Visual Analog Scale (VAS) is typically used for older children and adults who can understand and indicate their level of pain by marking a point on a line. This scale is not appropriate for infants due to their developmental stage and inability to communicate or understand the concept of the scale.

Choice C reason: The Oucher pain scale includes both a photographic scale with pictures of children's faces showing different levels of pain and a numerical scale. While it is designed for children aged 3 to 12 years, it is not suitable for infants, as they cannot verbally express their pain or point to a photograph to indicate their pain level.

Choice D reason: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is an appropriate choice for assessing pain in infants and young children who are non-verbal. It involves observing specific behaviors and assigning a score from 0 to 2 for each category, resulting in a total score between 0 and 10. This observational tool allows healthcare providers to assess pain levels based on the infant's behavior and physiological responses.