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 C
Explanation
Choice A Reason:
"You will have your dressing removed 12 hours after the procedure." This information might be pertinent, but it's not the most critical aspect to highlight in pre-procedural teaching for a 10-year-old child.
Choice B Reason:
"You will be on bed rest for 2 days after the procedure." While some rest might be recommended after the procedure, stating a specific duration of bed rest might cause unnecessary anxiety for the child. It's important to provide accurate information without causing undue stress.
Choice C Reason:
"You will need to keep your leg straight for 8 hours following the procedure." This instruction is relevant for post-procedural care after arterial cardiac catheterization. It's important to keep the leg straight to prevent bleeding from the catheter insertion site. Explaining this in child-friendly language would be beneficial.
Choice D Reason:
"You will be on a clear liquid diet for 24 hours following the procedure." While dietary instructions might be given after the procedure, specifying a clear liquid diet might not be the most crucial information to emphasize in pre-procedural teaching for a 10-year-old child.
Correct Answer is B
Explanation
Choice A Reason:
Constipation is incorrect. While bowel obstruction might occur due to the nature of intussusception, it usually presents with a different pattern of symptoms such as sudden, severe abdominal pain, vomiting, and sometimes, passing of "currant jelly" stool, which is a mixture of blood and mucus.
Choice B Reason:
Sausage-shaped abdominal mass is correct. This type of abdominal mass might be palpable during the assessment. It's a classic sign associated with intussusception. The mass can often feel like a sausage-shaped or tubular lump in the abdomen.
Choice C Reason:
Board-like abdomen is incorrect. A board-like abdomen with rigidity is a sign more commonly associated with conditions like peritonitis, which involves inflammation or infection of the abdominal lining, but it's not typically seen in intussusception.
Choice D Reason:
Increased urinary output is incorrect. Intussusception doesn't directly cause increased urinary output. This finding is less likely to be associated with this specific condition.
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