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: This is not the correct answer because Synagis® is a monoclonal antibody that is given as a prophylaxis to prevent severe RSV infection in high-risk infants. It is not effective as a treatment for RSV bronchiolitis.
Choice B reason: This is not the correct answer because antiviral medication is not routinely recommended for RSV bronchiolitis, as it has not been shown to improve outcomes. Limiting fluids and giving antitussives may also be harmful, as they can cause dehydration and suppress the cough reflex.
Choice C reason: This is not the correct answer because IV antibiotics are not indicated for RSV bronchiolitis, which is a viral infection. Antibiotics may increase the risk of antibiotic resistance and adverse effects.
Choice D reason: This is the correct answer because oxygen mist therapy can help humidify the air and relieve the respiratory distress. IV fluids can prevent dehydration and maintain electrolyte balance. Hand washing can prevent the spread of RSV infection to other patients and staff.
Correct Answer is C
Explanation
Choice A reason: Fidelity is the principle of being faithful and loyal to one's commitments and obligations. It is not directly related to the situation, although the nurse may have a duty to respect the parent's wishes.
Choice B reason: Equality is the principle of treating everyone fairly and impartially. It is not relevant to the situation, as there is no issue of discrimination or favoritism involved.
Choice C reason: Autonomy is the principle of respecting the right of individuals to make their own decisions. It is the most applicable to the situation, as the nurse recognizes the parent's authority to decide what is best for their child.
Choice D reason: Justice is the principle of distributing benefits and burdens equitably and according to valid criteria. It is not pertinent to the situation, as there is no conflict of interest or allocation of resources involved.
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