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 D
Explanation
Rationale:
A. Children with sickle cell anemia should receive all recommended immunizations to protect against infections, which can trigger a sickle cell crisis.
B. Participating in sports should be done with caution, and activities that lead to dehydration or overexertion should be avoided.
C. Over-the-counter medications should be used cautiously and under the guidance of a healthcare provider, as some medications may not be suitable for children with sickle cell anemia.
D. Ensuring adequate hydration is crucial for preventing sickle cell crises. Dehydration can increase blood viscosity, leading to sickling of the red blood cells and subsequent pain and complications.
Correct Answer is A
Explanation
Rationale
A. Testing urine for ketones is important during illness as it can indicate the presence of ketoacidosis, a potentially life-threatening complication in children with type 1 diabetes.
B. Withholding insulin during illness is dangerous, as the body may require more insulin due to increased stress and glucose production.
C. While notifying the provider for high blood glucose levels is essential, it is not the first action to take. Monitoring for ketones is crucial during illness.
D. Limiting fluid intake is not advised during illness, as adequate hydration is important to prevent dehydration and assist in glucose regulation.