# 將每位個案拖曳至其情境描述中最適當的疼痛評估工具。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393519&lang=zh-tw  
> language: zh-TW  
> subject: Nonpharmacological Comfort  
> category: BCC

## 題目

將每位個案拖曳至其情境描述中最適當的疼痛評估工具。

**1.** 清醒的術後成人，能描述疼痛並選擇一個數字

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

**2.** 理解0到10量表的輕度認知障礙老人

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

**3.** 能自我報告且理解臉譜量表的8歲兒童

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

**4.** 能指出符合目前疼痛臉譜的5歲兒童

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

**5.** 術後無法自我報告的6個月大嬰兒

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

**6.** 在疼痛性換藥過程中尚無語言能力的2歲兒童

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

**7.** 已無法自我報告疼痛的重度失智症老人

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

**8.** 在重新擺位時無法溝通的插管重症成人

Select a category
CPOT
FLACC
PAINAD
Wong-Baker FACES
Numeric Rating Scale 0–10

## 解析

對於能理解並量化疼痛的個案，使用數字評分量表。臉譜自我報告量表可幫助理解臉譜格式的兒童。FLACC是適用於無法自我報告的嬰幼兒的觀察工具。PAINAD專為重度失智症設計，而CPOT適用於無法溝通的重症成人，包括使用呼吸器的個案。

## 深入解析

快速解答
首先詢問，這位個案能可靠地自我報告嗎？若能，使用適當的自我報告量表；若不能，則依族群選擇已驗證的行為工具。

為何此為正確答案
NRS和臉譜量表測量個案本人的報告。FLACC觀察兒童行為，PAINAD針對重度失智症的疼痛行為，而CPOT評估無法溝通的重症成人的行為疼痛指標。

舊版修正
先前的題目將FLACC分配給插管成人。成人重症驗證研究支持CPOT為更適合的族群專用工具。主要研究
1CPOT在成人重症的驗證
2PAINAD的發展與心理計量評估
3Wong-Baker FACES在兒科急診照護的驗證

## 臨床情境

跨族群的疼痛評估
只要個案能可靠地報告疼痛，就應使用自我報告。當無法進行自我報告時，應選擇適合個案年齡及臨床族群的已驗證行為工具。

## 重要概念

- **CPOT** — Critical-Care Pain Observation Tool，適用於無法可靠自我報告的重症成人。
- **PAINAD** — Pain Assessment in Advanced Dementia，適用於重度失智症個案的觀察工具。
- **FLACC / PAINAD** — FLACC用於非語言兒童；PAINAD用於進階失智症成人 — 皆為行為觀察工具。

## 相同主題題目

- [A 68-year-old client with end-stage pancreatic cancer is receiving morphine 4 mg IV every …](https://mymerci.kr/pages/nclex_q.php?qn_id=363265&lang=zh-tw)
- [A nurse is caring for a 78-year-old client receiving comfort-focused end-of-life care. The…](https://mymerci.kr/pages/nclex_q.php?qn_id=364304&lang=zh-tw)
- [A nurse is caring for an 84-year-old client with end-stage Alzheimer disease admitted to i…](https://mymerci.kr/pages/nclex_q.php?qn_id=368152&lang=zh-tw)
- [A 58-year-old male is on postoperative day 1 following laparoscopic cholecystectomy. He ra…](https://mymerci.kr/pages/nclex_q.php?qn_id=372689&lang=zh-tw)
- [A nurse reviews a postoperative comfort plan. Classify each intervention according to how …](https://mymerci.kr/pages/nclex_q.php?qn_id=393399&lang=zh-tw)
- [Place the nursing actions in order for a hospice client who develops distressing shortness…](https://mymerci.kr/pages/nclex_q.php?qn_id=395540&lang=zh-tw)
- [A client with chronic primary low back pain is developing a nonsurgical plan. For each fin…](https://mymerci.kr/pages/nclex_q.php?qn_id=396150&lang=zh-tw)
- [A client with a new colostomy is learning pouch care. Which statement indicates correct un…](https://mymerci.kr/pages/nclex_q.php?qn_id=396628&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=393519&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=393519&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=393519&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=393519&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=393519&lang=vi)

---

More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw)

_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_