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A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?

A.

Rhythmic respirations

B.

Absent cry

C.

Resisting care

D.

Relaxed posturing

Answer and Explanation

The Correct Answer is C

A. "Rhythmic respirations." Normal, rhythmic breathing is not typically associated with pain. Pain may cause labored, irregular, or rapid breathing.
B. "Absent cry." The FLACC scale assesses crying as an indicator of pain. However, an absent cry does not suggest pain. A strong, continuous cry or moaning may indicate discomfort.
C. "Resisting care." Clients with pain often resist movement, care, or interventions due to discomfort or distress. This is a key indicator of pain in the FLACC scale (Activity or Consolability sections).
D. "Relaxed posturing." A relaxed posture suggests comfort, while pain often leads to rigid or tense positioning.


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Related Questions

Correct Answer is C

Explanation

A. Give the adolescent a short story pamphlet about puberty. While educational materials about puberty can be helpful, they do not provide specific information about a pelvic examination.
B. Describe the steps to the adolescent's guardian. The explanation should be directed to the adolescent to ensure they understand and feel comfortable. The guardian may be included if the adolescent prefers.
C. Show an online video that demonstrates what to expect. A visual demonstration can help reduce anxiety by familiarizing the adolescent with the procedure in a clear and informative way.
D. Use an anatomically correct puppet to demonstrate. Puppets are more appropriate for explaining procedures to younger children, not adolescents.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The client is at risk for developing deep vein thrombosis (DVT) due to their immobility.

Rationale:

  • Swelling and tenderness in the calf are key signs of DVT, which is a common complication of immobility after a stroke.

  • Immobility leads to venous stasis, increasing the risk of clot formation.

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