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
A productive cough is not a typical finding in early-stage Hodgkin’s lymphoma. Respiratory symptoms are more commonly associated with other conditions.
Choice B rationale
Bone and joint pain are not typical findings in early-stage Hodgkin’s lymphoma. These symptoms are more commonly associated with other conditions such as metastatic cancer or rheumatoid arthritis.
Choice C rationale
Intermittent hematuria is not a typical finding in early-stage Hodgkin’s lymphoma. Hematuria is more commonly associated with urinary tract infections or kidney conditions.
Choice D rationale
Enlarged lymph nodes are a common finding in early-stage Hodgkin’s lymphoma. This condition is characterized by the presence of Reed-Sternberg cells in the lymph nodes, leading to their enlargement.