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:

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: This is not correct because the mother's action is not intended to calm or punish the child for having a tantrum. It is a traditional healing method that aims to restore the balance of energy in the body.

Choice B reason: This is correct because the mother's action is a form of folk medicine known as coining or cao gio. It involves rubbing a coin or a spoon on the skin with oil or ointment to create red marks or bruises. It is believed to release the wind or bad energy that causes illness or pain.

Choice C reason: This is not correct because the mother's action is not a form of discipline or correction. It is a way of showing care and concern for the child's well-being.

Choice D reason: This is not correct because the mother's action is not abusive or harmful. It is a cultural practice that is based on a different understanding of health and disease. It may look alarming to outsiders, but it is not intended to hurt or injure the child.

A. Consistent growth pattern on the 25th percentile B. A contusion on the child's leg C. Fearful behavior when the nurse enters the room D. Inconsistent story on the child's injury.

Correct Answer is D

Explanation

Choice A reason: A consistent growth pattern on the 25th percentile is not an indicator of child abuse. It means that the child is growing normally and is within the expected range for their age and gender.

Choice B reason: A contusion on the child's leg is not necessarily an indicator of child abuse. It could be a result of accidental injury or normal play. However, the nurse should assess the location, size, shape, and color of the bruise, and compare it with the parents' explanation.

Choice C reason: Fearful behavior when the nurse enters the room is not a specific indicator of child abuse. It could be a sign of anxiety, shyness, or discomfort in an unfamiliar setting. The nurse should try to establish rapport with the child and use developmentally appropriate communication techniques.

Choice D reason: An inconsistent story on the child's injury is a strong indicator of child abuse. It suggests that the parents are trying to hide or cover up the cause of the injury, or that they are not aware of how the injury occurred. The nurse should document the discrepancies and report any suspicions of abuse to the appropriate authorities.

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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:

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Naxlex Comprehensive Predictor Exams

The nurse discovers welts on the back of a child whose parents identify as 1st generation Vietnamese. The mother states she rubbed the edge of a coin on her child's oiled back. The nurse should recognize that this is:

Correct Answer is B

Explanation

When obtaining a history from parents of a 4-year-old child, what indicator should prompt the nurse to consider suspected child abuse?

Correct Answer is D

Explanation

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