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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Dose The dose (5 mg) is clearly stated.
B. Time The prescription does not specify the frequency (e.g., every 4 hours PRN pain). The nurse should clarify how often the medication should be given.
C. Medication The medication (morphine) is clearly stated.
D. Route The route (IV bolus) is clearly specified.
Correct Answer is D
Explanation
A. "Direct all communication through the client's family." While family members may assist in communication, they may omit, alter, or misunderstand medical information. Using a trained medical interpreter ensures accurate and confidential communication.
B. "Limit instructions to simple and short one-sentence instructions." While clear, simple instructions are helpful, language barriers still exist. This does not fully address the client’s difficulty in understanding.
C. "Ask a coworker who speaks the client's language to translate information." A coworker may not be a certified medical interpreter and could misinterpret critical information. Medical translation should always be done by a qualified interpreter.
D. "Find an available interpreter to help with communication." A trained medical interpreter provides accurate, unbiased, and professional translation, ensuring that the client fully understands their care and can make informed decisions.
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