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 A
Explanation
Choice A reason: This is the most comprehensive and accurate way of assessing a child's pain, as it takes into account the child's own perception, the parent's observation, and the objective signs of pain.
Choice B reason: This is not the best approach, as the parents may not be able to accurately rate the child's pain, especially if the child is too young or has communication difficulties.
Choice C reason: This is not the best approach, as behavioral clues may not always reflect the intensity or quality of pain, and may be influenced by other factors such as fear, anxiety, or coping strategies.
Choice D reason: This is not the best approach, as physiological measures may not always correlate with pain, and may be affected by other variables such as medication, stress, or illness.
Correct Answer is C
Explanation
Choice A reason: This is not appropriate because it may make the parents feel excluded or suspicious. It may also make the girl feel uncomfortable or scared. The parents have the right to be present and involved in their daughter's care, unless they pose a threat to her safety.
Choice B reason: This is not appropriate because it may offend or upset the parents and the girl. It may also damage the trust and rapport between the provider and the family. The provider should not make assumptions or accusations based on the girl's symptoms.
Choice C reason: This is appropriate because it respects the parents' authority and the girl's privacy. It also allows the provider to rule out pregnancy as a possible cause of the abdominal pain, and to offer appropriate counseling and treatment if needed.
Choice D reason: This is not appropriate because it may miss a potential diagnosis or complication. The provider should not rely solely on the parents' or the girl's statements about sexual activity, as they may be inaccurate or dishonest. The provider should follow the standard of care and perform a pregnancy test for any female of childbearing age with abdominal pain.
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