A nurse is preparing to assess a non-verbal child’s pain level using the FLACC Scale.
The nurse knows that this scale rates five behavioral indicators.
Which of the following statements would be appropriate for the nurse to say during this assessment?
“I will observe your facial expression.”..
“I will watch how you move your legs.”..
“I will note your activity level.”..
“I will listen to your cry and observe your consolability.”..
The Correct Answer is D
Choice A rationale:
I will observe your facial expression.”..
This statement is not appropriate for assessing pain in a non-verbal child using the FLACC Scale because it does not address the five behavioral indicators the scale measures.
The FLACC Scale assesses facial expression, leg movement, activity level, cry, and consolability.
Choice B rationale:
I will watch how you move your legs.”..
This statement is also not appropriate for using the FLACC Scale as it only focuses on one of the five behavioral indicators.
While leg movement is assessed, it's crucial to evaluate all indicators for a comprehensive pain assessment.
Choice C rationale:
I will note your activity level.”..
This statement is partially correct, as the FLACC Scale does assess activity level.
However, it does not cover all the indicators, and it's essential to mention the other components for a complete assessment.
Choice D rationale:
I will listen to your cry and observe your consolability.”..
This statement is the most appropriate choice.
The FLACC Scale rates five behavioral indicators, and this statement acknowledges two of them: cry and consolability.
A comprehensive assessment should include all five indicators for an accurate pain evaluation in non-verbal children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
The FLACC Scale (Face, Legs, Activity, Cry, Consolability) is typically used for infants and young children who cannot effectively communicate their pain through verbal means.
This tool is not suitable for children aged 5 years and older as they can often express their pain verbally and can use more appropriate pain assessment tools.
Choice B rationale:
The Wong-Baker FACES Pain Rating Scale is a suitable tool for children aged 5 years and older.
It uses a series of faces depicting various levels of pain, making it easier for children to express their pain intensity.
This tool is particularly useful for children who can understand and communicate their feelings but may have difficulty with numerical scales.
Choice C rationale:
The Numeric Rating Scale (NRS) is a suitable tool for children aged 5 years and older.
It asks the child to rate their pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable.
Children in this age group can often understand and use numerical scales effectively.
Choice D rationale:
The Visual Analog Scale (VAS) is not typically recommended for children aged 5 years and older.
It requires the ability to mark a point on a line to indicate pain intensity, which can be challenging for young children.
Other tools like the Wong-Baker FACES Pain Rating Scale or the Numeric Rating Scale are more appropriate for this age group.
Choice E rationale:
None of the above" is not the correct choice, as options B, C, and D are suitable for children aged 5 years and older.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale:
The FLACC Scale is appropriate for assessing pain in non-verbal children, particularly those with limited communication abilities or cognitive impairments.
Choice B rationale:
The Wong-Baker FACES Pain Rating Scale is suitable for children who can use a simple visual scale to indicate their pain level.
It's especially helpful for children who can express themselves through drawings or symbols.
Choice C rationale:
The Numeric Rating Scale (NRS) is a reliable tool for assessing pain in children who can understand and use numbers.
It allows children to rate their pain on a numerical scale.
Choice D rationale:
The Visual Analog Scale (VAS) is another tool for older children who can comprehend and use a visual representation to indicate their pain level.
It involves marking a point on a line to represent pain severity.
The Pediatric Pain Questionnaire (PPQ) is not a commonly used pain assessment tool for children, and its effectiveness may be limited.
Therefore, it's not one of the recommended options for pain assessment in children.
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