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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.
Which of the following findings would indicate a need for pain medication? Select all that apply.

Increased pulse rate.

Skin showing peripheral pallor.

Clenched fists.

Increased respiratory rate.

Restlessness.

Elevated temperature.

Answer and Explanation

Correct Answer : A,C,D,E,F

Choice A rationale

An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.

Choice B rationale

Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.

Choice C rationale

Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.

Choice D rationale

An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.

Choice E rationale

Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.

Choice F rationale

An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.

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Correct Answer is A

Explanation

Choice A rationale

Nitroglycerin is a medication that is commonly used to treat chest pain or angina. However, it is contraindicated in patients who have taken sildenafil (Viagra) within the last 24 hours due to the risk of severe hypotension, or low blood pressure. Sildenafil is a type of medication known as a phosphodiesterase-5 (PDE5) inhibitor, which works by relaxing the muscles in the walls of blood vessels. Nitroglycerin also works by relaxing blood vessels, so the combination of these two medications can cause a dangerous drop in blood pressure.

Choice B rationale

Aspirin is not typically withheld in patients experiencing chest pain. It is often given to patients who are suspected of having a heart attack because it works by preventing blood clots from forming and blocking the blood vessels of the heart.

Choice C rationale

Morphine is often administered to patients experiencing severe chest pain to help relieve the pain and reduce the workload of the heart. It is not typically withheld unless the patient has a known allergy or other contraindication.

Choice D rationale

Heparin is a blood thinner that is often administered to patients who are suspected of having a heart attack to prevent further blood clots from forming. It is not typically withheld unless the patient has a known allergy, other contraindication, or is at high risk of bleeding.

A. Confirm that this value is helpful in reducing cardiac risk. B. Encourage the client to reduce consumption of fatty foods. C. Ask the client about hereditary cardiac risk factors. D. Explain that the client may need medication therapy.

Correct Answer is A

Explanation

Choice A rationale

High-density lipoprotein (HDL) cholesterol is known as the “good” cholesterol because it helps remove other forms of cholesterol from your bloodstream. Higher levels of HDL cholesterol are associated with a lower risk of heart disease. Therefore, an HDL level of 85 mg/dL (2.2 mmol/L) is helpful in reducing cardiac risk.

Choice B rationale

Encouraging the client to reduce consumption of fatty foods is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

Choice C rationale

Asking the client about hereditary cardiac risk factors is not the most relevant action in this case. The client’s HDL level is already high, which is beneficial for heart health.

Choice D rationale

Explaining that the client may need medication therapy is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.
Which of the following findings would indicate a need for pain medication? Select all that apply.