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
White drainage on the eyelids is not a normal finding and should be reported to the surgeon. However, this is not a standard discharge instruction but rather a sign of potential infection.
Choice B rationale
Sleeping on the abdomen is not recommended after cataract surgery as it can increase pressure on the eye and disrupt healing. Patients are usually advised to sleep on their back or the unaffected side.
Choice C rationale
Avoiding lifting anything heavier than 4.5 kg (10 lb) for 1 week is a standard instruction to prevent increased intraocular pressure and ensure proper healing of the surgical site.
Choice D rationale
Bending at the waist to pick up objects can increase intraocular pressure and should be avoided. Patients are advised to bend at the knees instead.
Correct Answer is B
Explanation
Choice A rationale
Vision may be temporarily blurred after intraocular lens surgery, but significant vision reduction for 48 hours is not typical and should be reported to a healthcare provider.
Choice B rationale
Restricting lifting objects greater than 10 pounds is crucial to prevent increased intraocular pressure and potential complications after surgery.
Choice C rationale
Aspirin should be avoided as it can increase the risk of bleeding. Alternative pain relief methods should be used.
Choice D rationale
Warm compresses are not recommended as they can increase inflammation and discomfort. Cold compresses may be more appropriate.