A nurse is caring for an 18-month-old infant who is 12 hr postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?
Poker Chip Tool
Color tool
Numeric scale
FLACC scale
The Correct Answer is D
A. The Poker Chip Tool is used to assess pain in children who can understand the concept of "a few" to "lots" of pain, typically in older children. It is not appropriate for infants or toddlers.
B. The Color tool is used for children who can associate color with pain intensity, but it is generally for older children who can understand this system, not for infants.
C. The Numeric scale is designed for children who are old enough to understand and use numbers (typically older than 8 years). An 18-month-old would not be able to understand this scale.
D. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is specifically designed to assess pain in infants and nonverbal children. It uses behavioral indicators to rate pain intensity and is appropriate for an 18-month-old toddler.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is "{\"xRanges\":[93.828125,113.828125],\"yRanges\":[223,243]}"
Explanation
A. Lateral aspect: The preferred location for performing a heel stick on a neonate is the lateral (outer) aspect of the heel, avoiding the central area and the arch of the foot. This area contains fewer nerve endings and less tissue, making it safer and less painful for the infant. It also minimizes the risk of injury to the underlying bones, blood vessels, and nerves.
B. Heel: The heel is not recommended as a puncture site because it contains fat, bone, and nerves, and puncturing the heel could cause injury or complications such as osteochondritis (bone infection). This site also carries a higher risk of injury to blood vessels and tendons.
C. Medial aspect: The medial (inner) aspect of the heel is also not recommended because it is near the medial plantar artery and nerves. Puncturing this area could result in damage to these structures, leading to complications. The lateral aspect is a safer, preferred location.
Correct Answer is D
Explanation
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
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.