A nurse is completing a pain assessment on an infant. Which of the following pain scales should the nurse use?

FACES

Oucher

FLACC

Non-communicating children's pain checklist

Answer and Explanation

The Correct Answer is C

Choice A reason: The FACES scale is not typically used for infants as they cannot verbally express or select a face that correlates with their pain level.

Choice B reason: The Oucher scale requires a child to point to a face that shows how much pain they are feeling, which is not suitable for infants who cannot communicate their pain verbally.

Choice C reason: The FLACC scale is appropriate for infants as it assesses pain based on five categories of behavior: Facial expression, Leg movement, Activity, Cry, and Consolability.

Choice D reason: The Non-communicating children's pain checklist is designed for children with cognitive impairments and is not the best choice for assessing pain in infants.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: It is the nurse's responsibility to administer medication, not the caregiver's, to ensure proper dosage and method.

Choice B reason: Calculating the safe dosage is essential to avoid underdosing or overdosing, which can be harmful to the toddler's health.

Choice C reason: Offering juice after medication can help wash down the taste and ensure the medication is swallowed properly.

Choice D reason: Identifying the toddler by asking the caregiver ensures that the correct child receives the medication, which is a critical safety step.

Choice E reason: Asking the toddler to pick a toy can provide comfort and distraction, making the administration process smoother and less stressful for the child.

A. Sensation of being cold B. Heightened sense of hearing C. Difficulty swallowing D. Tachycardia E. Cheyne-Stokes respirations

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: A sensation of being cold can occur as the body's circulation diminishes and blood flow to the extremities decreases.

Choice B reason: A heightened sense of hearing is not typically a sign of impending death; this choice is incorrect.

Choice C reason: Difficulty swallowing can be a sign of impending death due to the body's muscles weakening and a decrease in reflexes.

Choice D reason: Tachycardia may occur as the heart tries to compensate for decreased function in other systems.

Choice E reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing, are a common sign of impending death.

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A nurse is completing a pain assessment on an infant. Which of the following pain scales should the nurse use?

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