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 A
Explanation
Keeping a baby rear-facing in the car seat until they reach the age of 2 years old or until they reach the maximum height and weight limits recommended by the car seat manufacturer is a crucial safety guideline. Rear-facing car seats provide better support for a baby's head, neck, and spine in the event of a crash, reducing the risk of severe injuries.
"I should place my baby in the car seat at a 90-degree angle." The correct positioning for a rear-facing car seat is typically between a 30 to 45-degree angle. This angle helps ensure the baby's airway remains open and prevents their head from flopping forward.
"I should position the car seat's retainer clip at the level of my baby's belly button." The retainer clip of the car seat should be positioned at armpit level, not at the level of the baby's belly button. The retainer clip is designed to secure the harness straps and should be placed across the chest, resting on the bony part of the shoulders.
"I should enable the airbag when my baby is in the front seat of the car." It is not safe to have a rear-facing car seat with a baby in the front seat of a vehicle with an active airbag. Airbags can pose a significant risk to infants due to the force with which they deploy. It is recommended to place a rear-facing car seat in the back seat of the vehicle and disable the airbag in the front passenger seat if the baby needs to ride in the front.
It is important for parents to receive proper education on car seat safety and follow the guidelines set forth by car seat manufacturers, national recommendations, and local laws and regulations.
Correct Answer is B
Explanation
b. "You feel upset by the responses of others."
The appropriate response by the nurse is to acknowledge and validate the client's feelings. Option b, "You feel upset by the responses of others," demonstrates empathy and reflects back the client's feelings, indicating that the nurse understands and acknowledges the client's distress.
Explanation for the other options:
a. "I think you should just ignore the others." This response dismisses the client's concerns and does not address the underlying issue of the client feeling hurt by the interactions with others. It is important for the nurse to address the client's feelings and provide support.
c. "Let's keep the focus of our discussion on your needs." While it is important to address the client's needs, it is also necessary to address the client's concerns and feelings related to the interactions with other clients. Ignoring or dismissing the client's concerns can further isolate the client and hinder their progress in the therapeutic environment.
d. "Everything will get beter once you get to know everyone." This response minimizes the client's feelings and does not provide immediate support or address the client's concerns. It is essential for the nurse to validate the client's emotions and explore strategies to address the issue of others making fun of the client.
In summary, the nurse should choose a response that acknowledges the client's feelings and demonstrates empathy. Validating the client's experience can help establish trust and provide a foundation for further therapeutic interventions.
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