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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Gently lift the traction weights off the floor when repositioning the client. Rationale: This choice is not recommended in the care of a client in skeletal traction. Traction weights should never be lifted off the floor as they provide the necessary counter traction to align and immobilize the fractured bone. Lifting the weights could disrupt the traction and jeopardize the healing process.
Choice B rationale:
Reduce intake of foods containing fiber while nonambulatory. Rationale: While constipation can be a concern for clients in skeletal traction due to decreased mobility, reducing fiber intake is not the appropriate intervention. Adequate fiber intake is important to promote regular bowel movements and prevent constipation. Hydration and mobility exercises are more suitable approaches to manage constipation.
Choice C rationale:
Perform passive range-of-motion exercises to the affected extremity every 2 hours. Rationale: Passive range-of-motion exercises are important to maintain joint mobility and prevent muscle atrophy in a nonambulatory client. However, performing these exercises every 2 hours might be excessive and could cause unnecessary discomfort for the client. Range-of-motion exercises are usually done every 4 to 8 hours to strike a balance between maintaining joint health and providing rest.
Choice D rationale:
Apply protective padding to the end of the pin sites. Rationale: This is the correct choice. Applying protective padding to the end of the pin sites is crucial to prevent pressure ulcers and infection. The pin sites are potential entry points for bacteria, and protecting them helps reduce the risk of infection. Padding also prevents pressure on the skin and underlying tissues, reducing the potential for pressure injuries.
Correct Answer is D
Explanation
Choice A rationale:
Popcorn can be problematic for a child with Crohn's disease. Crohn's disease is characterized by inflammation in the gastrointestinal tract, and certain high-fiber foods like popcorn can exacerbate symptoms, causing discomfort and potential irritation of the intestinal lining.
Choice B rationale:
Hot dogs are typically high in fat and can be difficult to digest, which can trigger symptoms in a child with Crohn's disease. Additionally, processed meats like hot dogs might contain additives that could worsen inflammation in the digestive tract.
Choice C rationale:
Dried apricots are also not the best choice for a child with Crohn's disease. Dried fruits are concentrated sources of fiber and can be tough on the digestive system, potentially leading to abdominal pain and diarrhea in individuals with inflamed intestines.
Choice D rationale:
Plain yogurt is a suitable food choice for a child with Crohn's disease. It is a good source of protein and calcium and contains probiotics that can promote gut health. Probiotics may help regulate the digestive system and alleviate some symptoms associated with Crohn's disease. However, individual tolerances may vary, so it's important to monitor the child's response to yogurt.
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