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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
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
Itching is a common symptom after cataract surgery, and the client should be reminded not to rub or place pressure on the eyes. This comment does not indicate a serious complication.
Choice B rationale
Sensitivity to bright light is also common after cataract surgery. The client can be advised to wear sunglasses to reduce discomfort. This comment does not indicate a serious complication.
Choice C rationale
Fear of falling is a valid concern, especially if the client has impaired vision or depth perception due to the eye patch. However, this comment does not indicate a serious complication that needs immediate reporting.
Choice D rationale
Severe pain in the eye after cataract surgery can indicate a complication such as increased intraocular pressure, infection, or hemorrhage. This comment should be reported to the provider immediately for further evaluation and intervention.