A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair.
Which of the following pain rating tools should the nurse use?
FACES Scale
FLACC Scale
Color tool
Numeric scale
The Correct Answer is B
b. FLACC Scale.
Explanation: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is a pain assessment tool commonly used for infants and young children who are unable to self-report their pain. It assesses five categories of behavior: facial expression, leg movement, activity level, cry, and consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the specific scale used. The scores are then totaled to provide an overall pain assessment.
The FACES Scale, also known as the Wong-Baker FACES Pain Rating Scale, is a tool commonly used for children who can understand and self-report their pain. It consists of a series of faces with different expressions representing varying degrees of pain.
The Color tool is not a recognized pain rating tool. It may refer to an assessment of skin color, which can be used to assess oxygenation or circulation but not specifically for pain.
The Numeric scale is a pain rating tool that involves asking the individual to rate their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. However, this scale may not be suitable for a 3-month-old infant who is unable to comprehend numbers or communicate effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The presence of alcohol on a nurse's breath raises concerns regarding impairment and the potential for compromised patient safety. It is crucial to prioritize patient safety and prevent any potential harm. Removing the nurse from the client care area ensures that immediate patient safety is addressed and minimizes the risk of any adverse events.
Call the supervisor to ask for another nurse: While involving the supervisor is important, it should not be the first action taken in this situation. The immediate priority is to address patient safety by removing the nurse from the client care area.
Assign clients to the remaining staff: Assigning clients to the remaining staff should not be the first action taken because it may compromise patient safety if the nurse in question is impaired. It is important to ensure that the nurse is removed from the client care area before reassigning the clients to other staff members.
Document objective findings about the situation: Documenting the objective findings about the situation is important for accurate record-keeping and reporting. However, it should not be the first action taken when immediate patient safety is at stake. Removing the nurse from the client care area is the priority.
Correct Answer is B
Explanation
A nurse collecting data on a client who has swelling of the lower leg should identify that moderate pain on the ankle of the affected extremity is a manifestation of compartment syndrome. Compartment syndrome is a painful condition that occurs when pressure within a muscle compartment increases to dangerous levels.
The other options are not typical symptoms of compartment syndrome.
a) An affected extremity being warm to touchis not a typical symptom of compartment syndrome.
c) A blanch time of 2 seconds in the toenail beds of the affected extremity is not a typical symptom of compartment syndrome.
d) Palpation of a +1 dorsal pedal pulse of the affected extremity is not a typical symptom of
compartment syndrome.
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