The nurse uses the FLACC behavioral scale to assess a 6-year-old's level of postoperative pain and obtains a score of 9. The nurse interprets this to indicate that the child is experiencing:
little to no pain.
mild pain.
moderate pain.
severe pain.
The Correct Answer is D
A. Little to no pain: A FLACC score of 0 indicates relaxation and comfort, reflecting no observable pain behaviors. A score of 9 is far above this range and does not correspond to minimal discomfort.
B. Mild pain: Mild pain is generally represented by FLACC scores between 1 and 3, showing occasional restlessness or minimal facial grimacing. A score of 9 indicates significantly more distress.
C. Moderate pain: Moderate pain corresponds to scores between 4 and 6, showing intermittent crying, tension, or discomfort that is manageable but evident. A score of 9 exceeds this range.
D. Severe pain: A FLACC score of 7–10 reflects severe pain, characterized by frequent crying, rigid body posture, restlessness, and difficulty being consoled. A score of 9 signifies intense discomfort requiring immediate pain management intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Newborns do not expand their lungs fully with each respiration.": While newborns may have shallow breathing due to immature respiratory muscles, lung expansion does not directly affect the accuracy of respiratory rate measurement.
B. "The rate and rhythm of breath are irregular in newborns.": Newborns commonly exhibit periodic breathing, where the rate and rhythm fluctuate with brief pauses. Counting for a full minute ensures an accurate average respiratory rate and helps detect any abnormal patterns such as apnea.
C. "Newborns are abdominal breathers.": Although newborns primarily use the diaphragm for breathing, resulting in visible abdominal movement, this characteristic does not affect the need to count respirations for a full minute.
D. "Activity will increase the respiratory rate.": While true that crying or movement increases respiration, the nurse counts the rate during quiet rest. The irregular rhythm not activity level is the key reason for measuring over a complete minute.
Correct Answer is C
Explanation
A. "I get sharp pain in my lower abdomen usually starting soon after my period comes.": This statement suggests dysmenorrhea, which refers to painful menstruation caused by uterine contractions or conditions like endometriosis, not abnormal uterine bleeding.
B. "I get really irritable and moody about a week before my period.": These symptoms are consistent with premenstrual syndrome (PMS), a hormonal and emotional response that occurs before menstruation, not a bleeding irregularity.
C. "I've been having bleeding off and on that's irregular and sometimes heavy.": This supports abnormal uterine bleeding, which is characterized by irregular, unpredictable, or excessively heavy bleeding outside the normal menstrual cycle. Such bleeding often indicates hormonal imbalance, uterine pathology, or systemic conditions.
D. "My periods have been unusually short but heavy lately.": While this may suggest menorrhagia or other menstrual changes, it is still a cyclical pattern. Abnormal uterine bleeding typically involves unpredictable timing or prolonged irregular bleeding beyond normal cycles.
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