A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?
FLACC scale
FACES scale
OUCHER scale
PANAD scale
The Correct Answer is A
Rationale:
A. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who cannot verbally communicate their pain, making it suitable for a 2-month-old.
B. The FACES scale is used for older children who can point to or choose faces that represent their pain level and is not suitable for a 2-month-old.
C. The OUCHER scale is used for children aged 3 to 13 years and includes pictures representing pain, so it is not appropriate for a 2-month-old.
D. The PANAD scale is not a standard pain rating scale used for infants and is less commonly used than the FLACC scale.
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Correct Answer is B
Explanation
Rationale:
A. Encouraging deep breathing is important for preventing pulmonary complications but is not the priority in managing a vaso-occlusive crisis.
B. Maintaining hydration through intravenous fluids is the priority as it helps to reduce blood viscosity and prevent further sickling of cells, which is critical in managing a vaso-occlusive crisis.
C. Active range-of-motion exercises are important but are not a priority during an acute vaso-occlusive crisis.
D. A protein-rich diet supports overall health but is not immediately relevant to the acute management of a vaso-occlusive crisis.
Correct Answer is B
Explanation
Rationale:
A. These vital signs are generally within expected ranges for a 2-year-old child.
B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.
C. These vital signs are within normal limits for a 2-year-old child.
D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.