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:
Shrug their shoulders against mild pressure. The accessory nerve controls the movement of the trapezius and sternocleidomastoid muscles. To assess this nerve, the nurse should ask the child to shrug their shoulders against mild resistance or pressure applied by the nurse's hands on the child's shoulders. This action assesses the strength and symmetry of the trapezius muscles.
Choice B Reason:
Move their tongue in all directions. This action assesses the function of the hypoglossal nerve (cranial nerve XII), which controls tongue movement.
Choice C Reason:
Follow a light in the six cardinal positions. This action assesses the function of the extraocular muscles and cranial nerves III, IV, and VI, which control eye movements.
Choice D Reason:
Show their teeth while smiling. This action primarily assesses the facial nerve (cranial nerve VII), which controls facial expressions, including smiling and showing teeth.
Correct Answer is A
Explanation
Choice A Reason:
Tachypnea is correct .Tachypnea, which refers to rapid breathing, especially when associated with respiratory distress or difficulty in breathing, can be concerning in infants with RSV infection. It could indicate respiratory compromise or worsening of the condition, requiring prompt medical attention and intervention.
Choice B Reason:
Pharyngitis (sore throat) is incorrect. While pharyngitis can be uncomfortable for the infant, it's a common symptom of RSV and may not always indicate an immediate worsening of the condition or respiratory compromise requiring urgent reporting.
Choice C Reason:
Rhinorrhea (runny nose) is incorrect. Similarly, rhinorrhea or a runny nose is a typical symptom of RSV and often occurs in viral respiratory infections without necessarily signaling an immediate need for intervention or urgent reporting.
Choice D Reason:
Coughing is incorrect. Coughing is also a common symptom of RSV and may not always indicate an immediate need for reporting unless it becomes severe or is associated with respiratory distress.
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