Difficulty: Medium
Average Score: 84%
Simulated
A nurse is evaluating the pain level of a toddler who is cognitively impaired to a nonpharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?
Correct answer
C
Rationale
The correct answer is C: FLACC. FLACC stands for Face, Legs, Activity, Cry, and Consolability and is a pain assessment tool specifically designed for nonverbal or cognitively impaired individuals like toddlers. The tool assesses the toddler's facial expressions, leg movements, activity level, crying, and ability to be consoled. This comprehensive evaluation helps the nurse accurately determine the toddler's pain level. Visual analog scale (A) and FACES scale (B) require the ability to communicate and understand abstract concepts, making them unsuitable for cognitively impaired toddlers. CRIES scale (D) is primarily used for infants and may not be as effective for toddlers.