How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is preparing to assess a non-verbal child’s pain level using the FLACC Scale.
The nurse knows that this scale rates five behavioral indicators.
Which of the following statements would be appropriate for the nurse to say during this assessment?

A.

“I will observe your facial expression.”..

B.

“I will watch how you move your legs.”..

C.

“I will note your activity level.”..

D.

“I will listen to your cry and observe your consolability.”..

Answer and Explanation

The Correct Answer is D

Choice A rationale:

I will observe your facial expression.”..

This statement is not appropriate for assessing pain in a non-verbal child using the FLACC Scale because it does not address the five behavioral indicators the scale measures.

The FLACC Scale assesses facial expression, leg movement, activity level, cry, and consolability.

Choice B rationale:

I will watch how you move your legs.”..

This statement is also not appropriate for using the FLACC Scale as it only focuses on one of the five behavioral indicators.

While leg movement is assessed, it's crucial to evaluate all indicators for a comprehensive pain assessment.

Choice C rationale:

I will note your activity level.”..

This statement is partially correct, as the FLACC Scale does assess activity level.

However, it does not cover all the indicators, and it's essential to mention the other components for a complete assessment.

Choice D rationale:

I will listen to your cry and observe your consolability.”..

This statement is the most appropriate choice.

The FLACC Scale rates five behavioral indicators, and this statement acknowledges two of them: cry and consolability.

A comprehensive assessment should include all five indicators for an accurate pain evaluation in non-verbal children.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

Choice A rationale:

Assuming the child is tired and will be fine in a little while is not appropriate when the child has a high pain score.

It's important to address the child's pain promptly.

Choice B rationale:

This is the correct choice.

When a non-verbal child with difficulty breathing scores high on the FLACC Scale, it indicates significant pain.

Administering pain medication promptly is necessary.

Choice C rationale:

Acknowledging the child's pain and expressing a commitment to help them feel better is a good approach, but it doesn't address the urgency of the situation.

The child's high pain score requires immediate action.

Choice D rationale:

Assuming the child is scared and there's no need to worry is not appropriate when the child has a high pain score.

Pain needs to be managed effectively.

Correct Answer is A

Explanation

Choice A rationale:

Please point to the face that best represents your pain.”..

This statement is appropriate for using the Wong-Baker FACES Pain Rating Scale.

The scale consists of faces with different expressions, and the child is asked to point to the one that best represents their pain intensity.

This choice aligns with the scale's methodology.

Choice B rationale:

Remember, the faces range from smiling to crying.”..

While this statement provides some information about the scale, it doesn't guide the child on how to express their pain level accurately.

It's essential to ask the child to point to the face that matches their pain, as mentioned in choice A.

Choice C rationale:

This scale is used to represent different levels of pain intensity.”..

This statement is informative but lacks the direct instruction for the child to choose a specific face.

To assess pain using the Wong-Baker FACES Pain Rating Scale, it's important to instruct the child explicitly.

Choice D rationale:

The face you choose will help us understand how much pain you are in.”..

This statement is informative but doesn't instruct the child to interact with the scale.

It's crucial to involve the child actively in the pain assessment by having them select the face that best represents their pain.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register