Author Question: The nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the ... (Read 71 times)

littleanan · **on:** Jun 28, 2018

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 FLACC assessment as ________. (Record your answer as a whole number.)

What will be an ideal response?

Question 2

Which dietary recommendations should a nurse make to an adolescent patient to manage constipation related to opioid analgesic administration (Select all that apply)?

a. Bran cereal
b. Decrease fluid intake
c. Prune juice
d. Cheese
e. Vegetables

yasmina · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS:
2
The FLACC scale is recorded per the following table:
0 1 2
Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking
Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints
Consolability Content, relaxed Reassured by occasional touching, hugging, or talking to; distractible Difficult to console or comfort

Answer to Question 2

ANS: A, C, E
To manage the side effect of constipation caused by opioids, fluids should be increased, and bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause constipation so it should not be recommended.