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 A
Explanation
Choice A rationale
Cataracts cause the lens of the eye to become cloudy, leading to a decreased ability to perceive colors. This is due to the scattering of light as it passes through the cloudy lens, which reduces the clarity and vibrancy of colors.
Choice B rationale
Loss of peripheral vision is more commonly associated with glaucoma, a condition where increased intraocular pressure damages the optic nerve.
Choice C rationale
Seeing bright flashes of light and floaters is typically a symptom of retinal detachment, a serious condition where the retina pulls away from its normal position.
Choice D rationale
Loss of central vision is often linked to macular degeneration, a condition that affects the central part of the retina responsible for sharp, detailed vision.
Correct Answer is C
Explanation
Choice A rationale
Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.
Choice B rationale
Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.
Choice C rationale
Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.
Choice D rationale
Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.