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 D
Explanation
A. Developing autonomy is typically associated with increased independence and exploring new skills, not behaviors seen in a distressed or hospitalized child.
B. While anxiety may be present, the behavior of turning away and thumb-sucking more strongly suggests regression.
C. Resentment toward the mother would not typically result in the described behavior of thumb-sucking and turning away from the nurse.
D. Regression is when a child reverts to earlier behaviors, such as thumb-sucking, as a coping mechanism in response to stress or separation from the primary caregiver.
Correct Answer is B
Explanation
A. Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
B. Body weight is the most reliable indicator of fluid loss, as it directly reflects changes in body fluid levels.
C. Blood pressure changes can occur with fluid loss but may not be as sensitive or immediate as changes in body weight.
D. Skin integrity is important to monitor, but changes in body weight provide a more direct measure of fluid status.
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