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 A
Explanation
A. A 2-year-old toddler should have more than six teeth by this age, and the eruption of only six teeth is a delay in expected development. Most children have 16 teeth by age 2.
B. Using two- or three-word phrases is appropriate for a 2-year-old and is a sign of normal language development.
C. Building a tower of six to seven cubes is an appropriate developmental milestone for a 2-year-old and indicates normal motor development.
D. Being able to pick up objects without falling is a normal gross motor skill for a 2-year-old.
Correct Answer is D
Explanation
A. While it is important to maintain confidentiality, the nurse must follow mandatory reporting laws for suspected abuse, which may require informing appropriate authorities.
B. While it may be important to acknowledge the harm done, directly labeling the parent's behavior as "wrong" could potentially escalate the situation and may not be helpful in building rapport with the adolescent.
C. Making assumptions about the behavior of another parent can be seen as judgmental and may not be helpful in addressing the adolescent’s concerns or in facilitating a safe environment for disclosure.
D. This response provides reassurance to the adolescent that they are not responsible for the abuse and helps to create a nonjudgmental, supportive environment, allowing the adolescent to feel safe and heard.
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