Question 1 of 6
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Using the FLACC (Face, Legs, Activity, Cry and Consolability) scale, how would the nurse score a patient who has an occasional frown, legs drawn up, and rigid jerking movement; moans occasionally; and can be reassured by occasional touching?
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- 9According to the patient’s behaviors, the correct interpretation of the FLACC pain scale would be a number lower than 9.
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- 6A score of 6 is not the correct interpretation of the FLACC pain scale, according to the patient’s behaviors.
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- 7A score of 7 is the correct interpretation of the FLACC pain scale.
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- 8According to the patient’s behaviors, the FLACC pain scale should be slightly lower than 8.
Question 2 of 6
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Which instrument would the nurse use to determine the amount of pain and to document the findings for a 6-year-old child experiencing pain?
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- Numbered pain scaleA numbered pain scale may be confusing for children who may not have a good understanding of the numerical concept.
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- FACES pain scaleThe FACES pain scale uses pictures of facial expressions to rate pain. This is typically the best pain scale to use with children.
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- Pieces of pain scaleChildren are better able to understand pictures compared to numerical scales or the quantified pieces scale.
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- Color pain scaleThe color scale may be used with older children, but younger children may have difficulty if there are more than 3 or 4 choices.
Question 3 of 6
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Which goal does the health care team use as the target for the patient experiencing pain?
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- Relieving painThe health care team collaborates to meet the goal: relief of pain. Assessing and evaluating pain are part of the nursing process and contribute to achieving the goal of pain relief.
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- Assessing painAlthough assessing pain is an important part of pain management, the health care team target is to relieve the patient’s pain.
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- Managing painControlling or managing pain may be an alternative; however, the overall goal of the health care team is to relieve the patient’s pain.
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- Evaluating painEvaluating pain is an important part of the nursing process. This action contributes to the health care team’s overall goal, which is achieving pain relief.
Question 4 of 6
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To collect data on the patient’s level of pain, the nurse asks the patient to select the number of paper straws that most accurately reflect the pain level. Which scale is the nurse using?
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- FLACCThe FLACC scale is used to assess patients who have cognitive impairments. FLACC stands for Face, Legs, Activity, Cry and Consolability. Occasionally frowns, 1,+ Tense 1,+ Squirms 1,+ Cries steadily 2,+ Inconsolable 2 = Total score is 7.
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- FACESThe Wong-Baker FACES scale uses images of a face crying. Patients select the image that most reflects their level of pain.
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- Pieces of painA pieces-of-pain scale uses five identical, plain objects that represent “pieces” of pain. The patient indicates the degree of pain by selecting the number of objects that equals the intensity of pain being experienced.
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- NumberedA numbered scale asks patients to rate their pain on a numbered scale.
Question 5 of 6
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Which pain assessment tool would the nurse use for a patient who has cognitive impairment and pain related to an ankle fracture?
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- FLACCThe FLACC scale is used for patients who are cognitively impaired. The nurse would assess the patient’s behavior in categories such as facial expression, limb movement, activity, crying, and consolability.
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- FACESFACES is a visual scale that depicts facial expressions that correlate with various levels of pain; it is frequently used with children.
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- COLORCOLOR can be used for older children who are instructed to select a color that correlates with a level of pain.
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- PIECESPIECES of pain uses objects; the patient is instructed to quantify the pain by selecting more or fewer objects.
Question 6 of 6
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Which is the best example of documentation for a patient who is reporting pain associated with a migraine headache?
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- Reports a headache and nausea, denies blurred visionHeadache, nausea, and blurred vision would be recorded as additional subjective symptoms.
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- States, “My pain is 8 out of 10, and it’s on my right forehead”The documentation that includes the patient’s own words is the best way to record the patient’s subjective experience.
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- Requests more pain medication; received two doses at the scheduled timesIf the patient requests additional medication, the nurse would collect data and document this in the record, such as “Patient states, ‘My pain is a 5 out of 10.’”
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- Spouse wants the patient to have more pain and nausea medicationWhen documenting, it is important to include data and the patient or spouse’s exact words. This document example is not specific enough and does not include patient data.