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 C
Explanation
Choice A rationale
Headaches and blurred vision are not specific to stage I Lyme disease. These symptoms can occur in many other conditions and are not the primary indicators of early Lyme disease.
Choice B rationale
Tremors and weakness are not typical early signs of Lyme disease. These symptoms are more associated with neurological involvement, which occurs in later stages of the disease.
Choice C rationale
Rash symptoms, specifically erythema migrans (a bull’s-eye rash), are the hallmark of stage I Lyme disease. This rash appears at the site of the tick bite and is a key diagnostic feature.
Choice D rationale
Painful joints are more commonly seen in later stages of Lyme disease when the infection has spread and caused more systemic involvement.
Correct Answer is D
Explanation
Choice A rationale
Actinic keratosis is a precancerous condition that appears as rough, scaly patches on sun-exposed skin.
Choice B rationale
Malignant melanoma is a more aggressive form of skin cancer that often appears as a new, unusual growth or a change in an existing mole.
Choice C rationale
Squamous cell carcinoma typically appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.
Choice D rationale
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly and waxy borders. It is the most common type of skin cancer and typically occurs in areas exposed to the sun.