A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?
FLACC scale
FACES scale
OUCHER scale
PANAD scale
The Correct Answer is A
A. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who cannot verbally communicate their pain, making it suitable for a 2-month-old.
B. The FACES scale is used for older children who can point to or choose faces that represent their pain level and is not suitable for a 2-month-old.
C. The OUCHER scale is used for children aged 3 to 13 years and includes pictures representing pain, so it is not appropriate for a 2-month-old.
D. The PANAD scale is not a standard pain rating scale used for infants and is less commonly used than the FLACC scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is a common manifestation of hydrocephalus in newborns. The increased cerebrospinal fluid (CSF) in the ventricles causes the skull to expand, which can lead to prominent and dilated scalp veins due to increased intracranial pressure.
B. Over-riding suture lines are more commonly associated with conditions like craniosynostosis or during the early stages of labor when the skull bones overlap. In hydrocephalus, the sutures are more likely to be separated rather than overridden due to the expansion of the skull.
C. This is not a typical manifestation of hydrocephalus. Instead, you would expect a more pronounced or bulging forehead due to increased intracranial pressure.
D. Hypertension is not typically a manifestation of hydrocephalus in newborns. Instead, the condition is more associated with signs of increased intracranial pressure and changes in head size.
Correct Answer is B
Explanation
A. The primary purpose of pancreatic enzymes is to aid digestion, not to improve metabolism.
B. Pancreatic enzymes are used to help digest fats, proteins, and carbohydrates, which is essential for children with cystic fibrosis who have pancreatic insufficiency.
C. Enzymes should be taken with meals and snacks, not before them.
D. Enzymes should be taken with or just before meals to ensure they work effectively during digestion.
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