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 A
Explanation
Choice A rationale:
After a tonic-clonic seizure, it's common for the person to inadvertently bite their tongue, cheeks, or lips during the convulsive movements. Checking the mouth for any signs of bleeding or injuries is essential to ensure the person's safety and provide appropriate care.
Choice B rationale:
Placing the child's head in a hyperextended position is not recommended after a seizure. In fact, it's important to keep the person's head and neck in a neutral position to prevent potential injury. Hyperextending the neck could lead to strain or other complications.
Choice C rationale:
Giving the child a drink of water immediately after a seizure is not necessary and might be unsafe. The child may still be disoriented or have difficulty swallowing immediately after the seizure. It's best to ensure the child's safety and monitor their condition before offering any fluids.
Choice D rationale:
Administering naloxone intramuscularly is not indicated for a tonic-clonic seizure. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. Seizures have a different underlying cause, and administering naloxone would not be effective or appropriate in this context.
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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