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 {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.

Rationale:

Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.

A. Positive Trousseau's sign B. Muscle cramps C. Tingling sensation around the lips D. Negative Chvostek's sign E. Abdominal distention

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

Explanation

A. Positive Trousseau's sign: A positive Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is a classic indicator of hypocalcemia due to increased neuromuscular excitability.
B. Muscle cramps: Hypocalcemia leads to increased nerve excitability, causing muscle cramps, spasms, and tetany.
C. Tingling sensation around the lips: This is a common early sign of hypocalcemia, known as perioral paresthesia, due to increased nerve excitability.
D. Negative Chvostek's sign: A client with hypocalcemia would have a positive Chvostek’s sign, which is facial twitching when the facial nerve is tapped.
E. Abdominal distention: Hypocalcemia is more associated with diarrhea and hyperactive bowel sounds, not abdominal distention, which is more typical of hypokalemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale:

A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

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