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
Administering an IM injection does not typically require a gown as personal protective equipment unless there is a risk of exposure to blood or body fluids.
Choice B rationale
Completing a dressing change requires a gown to protect against potential exposure to blood or body fluids.
Choice C rationale
Administering an intermittent IV bolus medication does not typically require a gown unless there is a risk of exposure to blood or body fluids.
Choice D rationale
Talking to the client at the bedside does not require a gown as there is no risk of exposure to blood or body fluids.
Correct Answer is C
Explanation
Choice A rationale
Pitting edema of the hands and fingers is not a typical finding in clients with systemic lupus erythematosus (SLE). Edema can occur in SLE, but it is more commonly associated with renal involvement and not specifically pitting edema of the hands and fingers.
Choice B rationale
Subcutaneous nodules on the ulnar side of the arm are more commonly associated with rheumatoid arthritis rather than SLE. SLE does not typically present with subcutaneous nodules.
Choice C rationale
A dry, red rash across the bridge of the nose and on the cheeks, known as a “butterfly rash,” is a classic sign of SLE. This rash is caused by inflammation of the small blood vessels in the skin and is often exacerbated by sun exposure.
Choice D rationale
A grey-colored, non-purpuric papular rash is not characteristic of SLE. The typical rash in SLE is the butterfly rash, which is dry, red, and raised.