A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?

Increased formula consumption

Increased crying episodes

Decreased respiratory rate

Decreased heart rate

Answer and Explanation

The Correct Answer is B

Crying is a common behavioral response to pain in infants, and it serves as an important indicator of discomfort. Infants may cry more intensely, have a high-pitched cry, or exhibit inconsolable crying when they are in pain. It is important for the nurse to assess the infant's pain level and provide appropriate interventions to alleviate the discomfort.

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Correct Answer is A

Explanation

Distracting the child with a different activity or redirecting their attention can help diffuse the situation and shift their focus away from the tantrum. Offering to play a game or engage in a preferred activity can help redirect their energy and emotions.

Telling the child that temper tantrums are not acceptable may not be effective as toddlers may not fully comprehend or control their emotions yet. Ignoring the tantrums can also be challenging as it may reinforce the behavior or escalate the intensity.

Physically restraining the child is not recommended as it can be distressing for the child and potentially cause harm. It is important to use positive and supportive strategies to manage and address temper tantrums in toddlers.

A. At the beginning B. Before examining the head and neck C. At the end D. Before auscultating the chest

Correct Answer is C

Explanation

A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.

B.Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.

C.Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible.If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.

D.If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.

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A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

Correct Answer is C

Explanation

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