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:
Type 1 diabetes mellitus is correct. Type 1 diabetes is considered a risk factor for cardiovascular disease due to its potential impact on blood vessels and the heart over time. Individuals with diabetes, especially poorly controlled diabetes, are at a higher risk of developing cardiovascular complications such as heart disease, stroke, and peripheral vascular disease.
Choice B Reason:
Orthostatic hypotension is incorrect. Orthostatic hypotension refers to a drop-in blood pressure when moving from a lying or sitting position to a standing position. While it can cause symptoms like dizziness or lightheadedness, it's not typically considered a direct risk factor for cardiovascular disease. However, it might be associated with other conditions or medications that could contribute to cardiovascular issues indirectly.
Choice C Reason:
BMI of 24 is incorrect. A BMI (Body Mass Index) of 24 falls within the normal weight range. While obesity (especially central obesity or higher BMIs) is a known risk factor for cardiovascular disease, having a BMI of 24 by itself is not considered a significant risk factor for developing cardiovascular issues.
Choice D Reason:
Family history of osteoporosis is incorrect. Osteoporosis is a condition characterized by weakened bones, not directly related to cardiovascular disease. A family history of osteoporosis doesn't inherently indicate an increased risk of cardiovascular disease unless there are other associated factors or conditions within the family history that contribute to cardiovascular issues.
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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