A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?
Visual Analog Scale.
FLACC.
Oucher.
Faces.
The Correct Answer is B
Choice A rationale
The Visual Analog Scale is used for older children and adults who can understand and communicate their pain level.
Choice B rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for assessing pain in infants and young children who are unable to communicate their pain verbally.
Choice C rationale
The Oucher scale is used for children aged 3 to 12 years and involves matching facial expressions to a pain level.
Choice D rationale
The Faces scale is used for children aged 3 years and older who can point to a face that best represents their pain level.
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Correct Answer is B
Explanation
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.
Correct Answer is C
Explanation
Choice A rationale
Drinking room temperature beverages can help minimize irritation in the mouth and throat, which is beneficial for clients with stomatitis. Cold or hot beverages can exacerbate the condition by causing discomfort and pain.
Choice B rationale
Taking a prescribed analgesic can help manage the pain associated with stomatitis. Pain management is crucial for maintaining the client’s comfort and ability to eat and drink.
Choice C rationale
Stomatitis is not contagious and cannot be spread to family members. This statement indicates a need for further teaching as it reflects a misunderstanding of the condition.
Choice D rationale
Chemotherapy can affect the immune system, making the client more susceptible to infections and conditions like stomatitis. This statement is accurate and does not indicate a need for further teaching.