The nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability: content, relaxed. The nurse records the patient's pain using the FLACC assessment as:
00
1
2
3
The Correct Answer is B
Choice A: 0 - This would indicate that the child shows no signs of discomfort or pain. However, the nurse observed an occasional grimace and squirming, tense activity, which are signs of mild discomfort.
Choice B: 1 - This is the correct answer. The FLACC scale assesses five categories: Face, Legs, Activity, Cry, and Consolability, each scored from 0-2. In this case, the child scored 1 for Face (occasional grimace) and 0 for all other categories, totaling a score of 1.
Choice C: 2 - A score of 2 would indicate more signs of discomfort or pain than observed. The child's legs were relaxed, there was no cry, and the child was consolable, which are all scored as 0.
Choice D: 3 - A score of 3 would suggest even more significant signs of discomfort or pain, which is not consistent with the nurse's observations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Calling the physician is not the first action because it would delay the immediate intervention of oxygen administration, which is critical for a patient with hypoxia. The physician should be notified after initiating oxygen therapy and assessing the patient's condition.
Choice B reason: Placing the patient on 10 L/min oxygen per nasal cannula is not the first action because it is too high of a flow rate for a two-year-old patient, and it could cause oxygen toxicity or barotrauma. The appropriate oxygen delivery device and flow rate should be determined based on the patient's age, weight, and clinical status.
Choice C reason: Assessing the patient is not the first action because it would also delay the immediate intervention of oxygen administration. The patient's pulse oximetry reading indicates severe hypoxia, which requires prompt treatment to prevent organ damage or death. The patient should be assessed after initiating oxygen therapy and monitoring vital signs.
Choice D reason: Administering oxygen and monitoring vital signs while calling the physician is the correct answer because it provides the most effective and timely response to the patient's hypoxia. Oxygen administration improves the patient's oxygen saturation and tissue perfusion, while vital sign monitoring helps to evaluate the patient's response to therapy and identify any complications. Calling the physician informs them of the situation and allows them to order further interventions or tests as needed.
.
Correct Answer is B
Explanation
Choice A: True - While it is true that a significant proportion of prisoners have experienced abuse in their childhood, the statement that over half of all violent offenders in prison were physically or sexually abused as children is not accurate according to available data¹²³.
Choice B: False - This is the correct answer. According to a report by the Ministry of Justice in the UK, a large number of prisoners have experienced adverse childhood experiences, but the percentage does not exceed half¹. Similarly, a survey of men in Her Majesty's Prison Parc in South Wales found that more than 8 in 10 had experienced at least one adverse childhood experience, but this includes a range of experiences beyond physical and sexual abuse². Furthermore, data from the U.S. indicates that less than 20% of state prison inmates reported experiencing abuse before the age of 18³.
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