Practice Question
A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?
Answer Choices:
Correct Answer:
Resisting care
Rationale:
🧩 The FLACC scale assesses Face, Legs, Activity, Cry, Consolability to quantify pain in nonverbal or cognitively impaired clients.
🧩 Resisting care reflects abnormal Activity/Consolability (e.g., guarding, agitation, pulling away), which increases the FLACC score and indicates pain/discomfort.
🧩 Rhythmic respirations and relaxed posturing are consistent with comfort and typically correspond to low/zero FLACC scores.
🧩 An absent cry does not rule out pain, but without other pain behaviors, it usually does not raise the FLACC score; behavioral cues like resisting care are more indicative.
🧩 Elevated FLACC findings should prompt timely PRN analgesia and reassessment to document response.
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This question is from ☑️ ATI-RN Fundamentals-Miami Regional University which contains 37 questions.
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☑️ ATI-RN Fundamentals-Miami Regional University
37 Questions
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- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4