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

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 nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

Correct answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.

3. A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate constitutes a negligent act?

Correct answer: D

Rationale: Negligent acts in nursing include various errors that can harm the client, such as medication errors, intravenous therapy errors, burns, falls, failure to use aseptic technique, failure to provide adequate monitoring, and failure to report significant changes in a client's condition. In this scenario, using clean gloves to change a gastrostomy tube dressing is a negligent act because sterile gloves should be used when changing a dressing over broken skin. Choices A, B, and C are not negligent acts as they involve appropriate nursing actions: giving a verbal report, checking neurological signs, and contacting a healthcare provider about a change in a client's blood pressure.

4. Which of the following is not an indication for pelvic ultrasonography?

Correct answer: C

Rationale: Pelvic ultrasonography is commonly used to assess various conditions. Choices A, B, and D are all valid reasons for performing pelvic ultrasonography. Measuring uterine size helps evaluate conditions like fibroids, while detecting multiple pregnancies is essential for prenatal care. Furthermore, identifying foreign bodies can aid in diagnosing certain conditions. However, assessing renal size is typically not a primary reason for pelvic ultrasonography, making choice C the correct answer.

5. What can happen if a restraint is attached to a side rail or other movable part of the bed?

Correct answer: B

Rationale: Attaching a restraint to a movable part of the bed can lead to client injury if that part of the bed is moved before releasing restraints. This could result in the client getting caught or trapped, possibly causing harm. Choices C and D are incorrect because attaching restraints to movable parts of the bed is not intended to help the client stay in bed or improve posture; rather, it poses a risk of injury. Choice A is incorrect as it does not address the potential harm associated with using restraints on movable parts of the bed.

Similar Questions

The client has a new prosthetic hip, and the nurse is repositioning them. Which position should be avoided to prevent injury to the new prosthetic hip?
A case management clinical pathway for congestive heart failure might include all of the following except:
When planning play activities for a hospitalized school-age child, a nurse uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing which developmental goal?
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
When providing perineal care to a female client, how should the nurse perform the procedure?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses