Nokea
Using the FLACC pain scale, how should the LPN document pain for a non-verbal client with these findings: 1.Face-occasional grimacing 2.Legs-relaxed 3.Activity-Squirming 4.Cry-moans and whimpers 5.Consolability-distractible
- A. 5
- B. 4
- C. 3
- D. 8
Correct Answer: B
Rationale: The points add up like this: Face-1 Legs-0 Activity-1 Cry-1 Consolability-1 Total pain score-4
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The NSAID that is comparable to morphine in efficacy is:
- A. Feldene.
- B. Stodal.
- C. Toradol.
- D. Elavil.
Correct Answer: C
Rationale: Toradol is the first injectable NSAID equal to morphine in efficacy.
When making an occupied bed, it is important for the nurse to:
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy.
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct Answer: B
Rationale: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.
A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1°F at 4 a.m. The nurse determines that this is most likely due to:
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm. The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature. While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the sleep period shifts, temperature fluctuations also shift to match the new sleep patterns.
Perineal care to a female client by the nurse can be performed:
- A. Without gloves, pouring water from a sterile bottle
- B. Without gloves, having the client perform all care
- C. With gloves, washing the perineal area from front to back
- D. With gloves, washing the perineal area from back to front
Correct Answer: C
Rationale: Perineal care requires gloves and washing from front to back to prevent bacterial contamination of the urethra, ensuring infection control.
Pain tolerance in an elderly client with cancer should:
- A. Stay the same.
- B. Decrease.
- C. Increase.
- D. Cancer should have no effect on pain tolerance for an elderly client.
Correct Answer: B
Rationale: There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.