A nurse is caring for an 18-month-old infant who is 12 hours postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?
FLACC scale.
Color tool.
Poker Chip Tool.
Numeric scale.
The Correct Answer is A
Choice A rationale:
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is a pain assessment tool commonly used for infants and young children who cannot verbalize their pain. It assesses different behavioral and physiological indicators of pain, such as facial expressions, leg movement, activity level, crying, and response to consoling. Given that the infant is only 18 months old, this scale is appropriate for evaluating their postoperative pain.
Choice B rationale:
The Color tool is not a recognized pain assessment tool. It's essential to use validated and standardized pain assessment scales, and the Color tool does not fit this criterion.
Choice C rationale:
The Poker Chip Tool is not typically used for pain assessment in infants. It's often used with older children to assess pain intensity using a poker chip set that corresponds to different levels of pain. However, for an 18-month-old infant, behavioral assessments like the FLACC scale would be more suitable.
Choice D rationale:
The Numeric scale involves asking the patient to rate their pain on a numerical scale, often from 0 to 10. However, this scale is not appropriate for an 18-month-old infant who is likely unable to comprehend or use numbers to express their pain. The FLACC scale provides a more comprehensive assessment of pain in non-verbal or preverbal children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Insulin administration is not appropriate in this situation. The child's symptoms (slurred speech, diaphoresis, low blood glucose reading) indicate hypoglycemia, which is a state of low blood sugar. Administering insulin, which lowers blood glucose further, would exacerbate the hypoglycemia and could lead to more severe symptoms or even unconsciousness.
Choice B rationale:
Metformin is not indicated in this scenario. Metformin is an oral medication used to treat type 2 diabetes, not type 1 diabetes mellitus. The child in the scenario has type 1 diabetes, which is characterized by an absolute deficiency of insulin production.
Choice C rationale:
Offering a 6 oz diet soft drink is not the appropriate intervention for hypoglycemia. Diet soft drinks do not contain significant amounts of sugar, which is needed to rapidly raise the child's blood glucose levels. In cases of hypoglycemia, a source of quickly absorbable sugar, such as a regular soft drink or fruit juice, is recommended.
Choice D rationale:
Administering a 6 oz regular soft drink is the appropriate intervention in this situation. The child is experiencing hypoglycemia, which means their blood glucose levels are dangerously low. Regular soft drinks contain rapidly absorbable sugar that can quickly raise the child's blood glucose levels, alleviating the symptoms of hypoglycemia. The child's symptoms, including slurred speech and diaphoresis, are indicative of a need for immediate intervention to raise blood sugar levels.
Correct Answer is ["B","D"]
Explanation
Choice A rationale:
Allowing an adolescent driver to answer their phone while driving can lead to distraction, increasing the risk of accidents. Engaging in conversations on the phone diverts the driver's attention from the road, which is unsafe. It's crucial for drivers, especially new ones, to focus solely on driving to prevent accidents.
Choice B rationale:
This choice is correct. Not answering the phone while driving is a responsible behavior that indicates an understanding of the dangers of distracted driving. Parents should encourage their children to focus on the road and avoid distractions like phone calls, promoting safe driving practices.
Choice C rationale:
This statement is incorrect. Adolescents should continue wearing helmets when riding their bikes even after age 13. Wearing helmets helps prevent head injuries in case of accidents. While older adolescents might perceive themselves as less prone to accidents, they are still at risk, and helmets are essential for their safety.
Choice D rationale:
This choice is correct. Wearing appropriate protective clothing, like long pants, while driving an all-terrain vehicle (ATV) is crucial. Long pants can provide some degree of protection against scrapes, scratches, and minor injuries that can occur while operating an ATV. It's a safety measure that shows an understanding of the importance of protective gear.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.