using the flacc pain scale how should the lpn document pain for a non verbal client with these findings faceoccasional grimacing legsrelaxed activitys
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?

Correct answer: B

Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.

2. The goals of palliative care include all of the following except:

Correct answer: C

Rationale: The correct goal of palliative care is to provide comprehensive care that addresses the physical, emotional, social, and spiritual needs of the dying client until the end of life. Therefore, the statement 'no interventions are needed because the client is near death' is incorrect as interventions are still essential to ensure comfort and quality of life. Choices A, B, and D are all aligned with the goals of palliative care, focusing on improving the quality of life, providing holistic care, and supporting both the family and the client.

3. Which of the following enzymes is indicative of pancreatitis?

Correct answer: D

Rationale: Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. Pancreatitis is characterized by the inflammation of the pancreas, leading to the leakage of amylase into the bloodstream. Elevated levels of amylase are a key diagnostic marker for pancreatitis. Alkaline phosphatase is associated with liver and bone conditions, not pancreatitis. Acid phosphatase is more related to prostate health and is not specific to pancreatitis. Creatine phosphokinase is found in tissues like muscle and brain, and elevated levels are seen in conditions like muscle injury or heart attack, not pancreatitis.

4. Which of the following behaviors is least appropriate when dealing with fellow staff members?

Correct answer: C

Rationale: The least appropriate behavior when dealing with fellow staff members is to only report conflicts that interfere with client care. This choice implies ignoring or neglecting other conflicts that may affect team dynamics and the work environment. It is crucial to address and report all conflicts, whether they impact client care directly or not, to maintain a harmonious and effective working relationship within the healthcare setting. Providing positive feedback, constructive criticism, serving as a resource, and offering input for performance evaluations are all important and appropriate behaviors that contribute to a supportive and professional work environment. By focusing solely on conflicts that interfere with client care, essential issues that influence teamwork and overall staff morale may be overlooked, potentially leading to a negative impact on the work environment.

5. The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:

Correct answer: A

Rationale: In most states, indication of organ donor status is found on the client's driver's license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse. Therefore, the correct answer is finding evidence of the client's wishes regarding organ donation on the client's driver's license.

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