A nurse is evaluating an 8-month-old infant's pain level following the administration of hydrocodone. Which of the following pain scales would the nurse use?

A) "The client fell because the assistive personnel did not place nonskid slippers on the client.": This statement assigns blame to a specific individual (assistive personnel) for the fall, which is not appropriate for documentation. The nurse should focus on factual, objective information rather than assigning blame. Statements that imply fault without proper evidence or investigation should be avoided in medical records.

B) *Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom.'": This statement accurately reflects the client’s account of the incident, which is a critical part of the documentation. The nurse should include the client’s own words when describing the event, as it provides essential context and ensures that the record is clear and unbiased. This statement is objective and factual.

C) "The client does not appear to have any injuries resulting from the fall.": While it’s important to assess for injuries, this statement could be too vague. The nurse should document a detailed assessment of the client’s physical condition post-fall, including any injuries, signs, or symptoms of injury. It is important to be thorough and specific in documenting the client's condition after the fall.

D) "An incident report has been completed and sent to risk management.": This information should not be included in the medical record. Incident reports are separate documents that are used for internal review and safety improvement purposes. Including this information in the medical record could lead to confusion and may not be relevant to the clinical care of the client.

A) "It takes 2 months of scheduled use before this medication is effective.":
This statement is incorrect. Montelukast is a leukotriene receptor antagonist that works to prevent asthma symptoms and improve lung function. It typically takes a few days to a week for the medication to become effective, not 2 months. Immediate relief is not expected, but long-term benefits can be seen within a relatively short period after starting the medication.

B) "I will give this medication to my child every 2 hours if he is wheezing.":
This statement is incorrect. Montelukast is a maintenance medication that is taken on a daily basis to prevent asthma symptoms. It is not a rescue medication and should not be used every 2 hours when the child is wheezing. Rescue medications like short-acting beta-agonists (e.g., albuterol) should be used during an asthma attack or when wheezing occurs.

C) "I will give this medication to my child once daily in the evening.":
This statement is correct. Montelukast is typically taken once daily in the evening. It helps to reduce inflammation and prevent asthma symptoms, and taking it in the evening aligns with the medication's intended use for long-term control of asthma.

D) "I can stop giving my child this medication if he is taking steroids.":
This statement is incorrect. Montelukast is often used alongside steroids (inhaled corticosteroids) for managing asthma. The two medications work in different ways, and discontinuing montelukast while continuing steroids may not provide optimal asthma control. It is important to follow the healthcare provider's instructions regarding the use of both medications.