Exhibits

The nurse determines the client is in pain.

Which pain scales would be appropriate for this client? Select all that apply.

A. FLACC Postoperative Pain Scale: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is commonly used for infants and young children who cannot verbally report their pain. It assesses behavioral cues such as facial expressions, leg movement, activity level, crying, and ability to be consoled, making it appropriate for this 4-month-old infant.
B. Riley Infant Pain Scale: This scale is specifically designed for infants under 1 year of age. It evaluates facial expression, sleep patterns, movements, crying, and verbal cues to determine the level of discomfort. Since this infant is postoperative and unable to self-report pain, this scale is a useful tool.
C. Poker Chip Tool: This tool is used for older children, typically 4 years and above, who can understand the concept of counting and associating poker chips with pain intensity. It is not appropriate for a 4-month-old infant who lacks the cognitive ability to use symbolic representation.
D. Visual Analog Scale: This scale requires the client to mark pain intensity on a continuous line, making it appropriate only for older children (around 7 years and older) who understand abstract concepts. A 4-month-old infant cannot comprehend or use this scale.
E. Numeric: The numeric pain scale (0–10) is used for older children and adults who can assign a number to their pain. Infants and young children cannot use this scale, making it inappropriate for this client.
F. FACES: The Wong-Baker FACES Pain Rating Scale is designed for children 3 years and older who can recognize and correlate facial expressions with pain levels. A 4-month-old does not have the cognitive ability to use this scale reliably.

A. Begin prescribed intravenous antibiotic administration. While IV antibiotics are essential for treating bacterial infections such as epiglottitis, securing the airway is the priority in this child with severe respiratory distress. Antibiotic therapy should be initiated after airway stabilization to prevent further deterioration.
B. Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck. An MRI is not appropriate in an emergency airway situation, as it requires the child to remain still and may delay critical interventions. A clinical diagnosis of epiglottitis is based on symptoms, and confirmation is typically done with lateral neck X-rays only if the airway is stable.
C. Obtain bedside trays for intubation or tracheotomy by the healthcare provider. The child’s symptoms—high fever, drooling, anxiety, and a tripod sitting position—are classic signs of epiglottitis, a life-threatening condition caused by Haemophilus influenzae type B (Hib). Immediate airway management is critical, as swelling of the epiglottis can rapidly lead to complete airway obstruction. Equipment for emergency intubation or tracheotomy must be readily available.
D. Provide a nebulizer treatment with bronchodilators. Nebulized bronchodilators are used for conditions like asthma or croup but are ineffective in epiglottitis, which is caused by inflammation and swelling of the supraglottic structures. Administering nebulized treatments may further distress the child and increase the risk of airway obstruction.