A nurse is monitoring an infant who is receiving opioids for pain. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
Relaxed facial expression
Increased blood pressure
Limb withdrawal
Bradycardia
The Correct Answer is A
Choice A Reason:
Relaxed facial expression is correct. Opioids, when effectively managing pain, can lead to a more relaxed facial expression in infants. It's a common indicator that the pain is being controlled and the infant is experiencing relief.
Choice B Reason:
Increased blood pressure is incorrect. Opioids usually cause a decrease in blood pressure rather than an increase. Elevated blood pressure wouldn't typically signify a therapeutic effect of opioids; it might indicate other factors such as stress, discomfort, or an adverse reaction.
Choice C Reason:
Limb withdrawal is incorrect. Limb withdrawal is a reflex action and might occur in response to a stimulus. It's not a direct indicator of pain relief; rather, it's a reflexive response to a sensation.
Choice D Reason:
Bradycardia is incorrect. Bradycardia, a slowed heart rate, can be a side effect of opioid medications. However, it's not an indicator of the therapeutic effect of pain relief. In fact, bradycardia might signal an adverse reaction or a dose that's too high for the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Muscle rigidity is correct. Muscle rigidity can indicate several concerning issues postoperatively, such as complications from anesthesia, infection, or other underlying problems. It's crucial to report this finding promptly to the provider for further evaluation and appropriate management.
Choice BReason:
Some degree of abdominal pain is expected post-appendectomy, but the severity and persistence of the pain should be assessed further.
Choice CReason:
Heart rate of 63/min is within the normal range for some adolescents and might not be an immediate concern unless there are other accompanying symptoms.
Choice D Reason:
A temperature of 36.4°C (97.5°F) falls within the normal range for body temperature and might not be a cause for immediate concern unless it's accompanied by other symptoms or if there are signs of temperature changes (like fever) over time.
Correct Answer is C
Explanation
Choice A Reason:
Neck vein distention is incorrect. Neck vein distention is not a common symptom of aspirin poisoning. It might be seen in conditions like heart failure but is not typically associated with aspirin toxicity.
Choice B Reason:
Polyuria is incorrect. Excessive urination (polyuria) is not a typical symptom of acute aspirin poisoning. Aspirin toxicity more commonly presents with symptoms related to the central nervous system, respiratory distress, metabolic acidosis, and temperature dysregulation.
Choice C Reason:
Hyperpyrexia is correct. Acute aspirin poisoning can lead to an increased body temperature (hyperpyrexia) due to its effects on the central nervous system and interference with the body's temperature regulation mechanisms. Aspirin toxicity can result in alterations in the hypothalamus, leading to an elevated body temperature.
Choice D Reason:
Jaundice is incorrect. Jaundice, the yellowing of the skin and eyes, is not a characteristic finding of acute aspirin poisoning. It is more commonly associated with liver dysfunction or certain types of liver diseases but is not a typical manifestation of aspirin toxicity.
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