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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["18"]
Explanation
Step 1 is to calculate the infusion rate. The prescription is for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline.
So, the calculation would be (900 units ÷ 25,000 units) × 500 mL = 18 mL/hr.
Correct Answer is B
Explanation
Choice A rationale
Production of extra platelets is not the primary pathophysiological process in Disseminated Intravascular Coagulation (DIC). While the body may try to produce more platelets in response to the widespread clotting, this is not the cause of the coagulation problem.
Choice B rationale
Depletion of clotting factors is a key feature of DIC. In the initial phase of DIC, there is an overactive clotting process leading to the formation of small blood clots throughout the body’s blood vessels. This overactive clotting uses up platelets and clotting factors, leading to a state where the body is unable to control bleeding, which is the second phase of DIC34.
Choice C rationale
Inhibition of red blood cell production is not a primary feature of DIC. While DIC can lead to anemia due to blood loss from excessive bleeding, it does not directly inhibit the production of red blood cells.
Choice D rationale
Activation of complement pathways is part of the body’s immune response and is not the primary cause of the coagulation problem in DIC34.
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