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 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.
Correct Answer is D
Explanation
Choice A rationale
Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.
Choice B rationale
Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.
Choice C rationale
Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.
Choice D rationale
Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.