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
None
None
The Correct Answer is C
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: Choice B is incorrect because it only accounts for one of the two behavioral deviations noted by the nurse. Scoring a 1 would mean only one category, such as the facial expression, received a point while all others remained at 0. Since both face and activity were abnormal, this score is too low.
Choice C: This is correct because the FLACC scale assigns points based on specific behaviors. The "Face" assessment of an occasional grimace earns 1 point. The "Activity" assessment of squirming and tension earns another 1 point. With legs, cry, and consolability all scored at 0, the cumulative total for the patient is 2.
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 a good intervention because it disregards the parent's and the child's religious beliefs and values. It may also imply that the nurse knows better than the parent what is best for the child.
Choice B reason: This is not a necessary intervention because it does not address the immediate issue of the child's nutrition. It may also suggest that the nurse thinks the parent needs spiritual guidance or counseling.
Choice C reason: This is not a respectful intervention because it violates the parent's and the child's right to follow their dietary rules. It may also cause the parent and the child to feel guilty or conflicted.
Choice D reason: This is the best intervention because it honors the parent's and the child's preferences and practices. It also ensures that the child receives adequate and appropriate nutrition.
Correct Answer is A
Explanation
Choice A: 100 mg PO q8 hours - This would give a total of 300 mg per day. Given the child's weight of 11 kg, this results in a dosage of about 27 mg/kg/day, which is within the safe range of 20-40 mg/kg/day.
Choice B: 350 mg PO q8 hours - This would give a total of 1050 mg per day. This results in a dosage of about 95 mg/kg/day, which is more than twice the upper limit of the safe range.
Choice C: 220 mg PO q8 hours - This would give a total of 660 mg per day. This results in a dosage of about 60 mg/kg/day, which is above the safe range.
Choice D: 500 mg PO q8 hours - This would give a total of 1500 mg per day. This results in a dosage of about 136 mg/kg/day, which is more than three times the upper limit of the safe range.
Therefore, the only safe dosage among these options is 100 mg PO q8 hours. Always remember to double-check dosages and consult with a healthcare professional if you're unsure. Safety is paramount when it comes to medication administration.
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