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

Answer and Explanation

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.

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Correct Answer is C

No explanation

A. Administer aspirin for fever. B. Initiate airborne precautions, C. Assess the oral cavity for Koplik spots. D. Provide the child with a warm blanket

Correct Answer is B

Explanation

Choice A Reason:

Administer aspirin for fever is incorrect. Aspirin is contraindicated in children with varicella due to the risk of Reye's syndrome. Reye's syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella.

Choice B Reason:

Initiate airborne precautions is correct.Varicella is transmitted via airborne droplets. Use airborne precautions (negative air-flow rooms) for patients with varicella. If negative air-flow rooms are not available, isolate patients in closed rooms with no contact with people without evidence of immunity

Choice C Reason:

Assess the oral cavity for Koplik spots is incorrect. Koplik spots are associated with measles, not varicella. Varicella typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.

Choice D Reason:

Varicella can cause fever and discomfort, and providing a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is more important to initiate airborne precautions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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