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 D
Explanation
Choice A reason: The child's current vital signs are consistent with vital signs over the past 4 hours. This does not indicate that the child is in pain, as the vital signs may be within normal range or stable.
Choice B reason: The child becomes quiet when held and cuddled. This may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain.
Choice C reason: The child has just returned from the recovery room. This may indicate that the child is still under the influence of anesthesia or sedation, not that the child is in pain.
Choice D reason: The child is lying rigidly in bed and not moving. This is a sign of pain in children, as they may try to avoid movement or stimulation that could worsen their pain. The nurse should assess the child's pain level and administer pain medication as prescribed.
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