A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?

Rhythmic respirations

Absent cry

Resisting care

Relaxed posturing

Answer and Explanation

The Correct Answer is C

A. "Rhythmic respirations." Normal, rhythmic breathing is not typically associated with pain. Pain may cause labored, irregular, or rapid breathing.
B. "Absent cry." The FLACC scale assesses crying as an indicator of pain. However, an absent cry does not suggest pain. A strong, continuous cry or moaning may indicate discomfort.
C. "Resisting care." Clients with pain often resist movement, care, or interventions due to discomfort or distress. This is a key indicator of pain in the FLACC scale (Activity or Consolability sections).
D. "Relaxed posturing." A relaxed posture suggests comfort, while pain often leads to rigid or tense positioning.

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Correct Answer is A

Explanation

A. "Arrange to perform all nonessential tasks for the client at one time."
Grouping nonessential tasks reduces frequent disruptions, allowing the client to rest more effectively, which is essential for recovery.
B. "Encourage the client to sleep as much as possible during the day."
Excessive daytime sleeping can disrupt the client’s sleep-wake cycle, leading to difficulty sleeping at night.
C. "Perform routine hygiene for the client during the night."
Performing hygiene tasks at night can disturb the client’s rest and impact recovery.
D. "Remove limits on visiting hours for the client." Unrestricted visiting hours can increase noise and interruptions, making it harder for the client to get adequate rest.

A. Stop the transfusion. B. Place the client in high-Fowler's position. C. Obtain a prescription for a diuretic. D. Administer oxygen to the client. E. Administer epinephrine to the client.

Correct Answer is ["A","B","C","D"]

Explanation

A. Stop the transfusion. The first action is to stop the transfusion to prevent further fluid overload.
B. Place the client in high-Fowler's position. This position reduces venous return to the heart and improves breathing and oxygenation.
C. Obtain a prescription for a diuretic. Diuretics (e.g., furosemide) help remove excess fluid, relieving pulmonary congestion and reducing strain on the heart.
D. Administer oxygen to the client. Oxygen helps relieve hypoxia caused by fluid buildup in the lungs.
E. Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not circulatory overload. There is no indication of an allergic reaction in this scenario.

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A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?

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