The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.
Clenched fists.
Increased temperature.
Restlessness.
Peripheral pallor of the skin.
E Increased respiratory rate.
Increased pulse rate.
Correct Answer : A,C,E,F
Rationale
A. Clenched fists can be a sign of pain in infants. Infants may reflexively clench their fists as a response to discomfort or pain. This behavior is commonly observed during painful procedures or when experiencing pain.
B. While fever can sometimes accompany pain due to inflammation or stress response, it is not typically a reliable indicator of pain in the absence of other signs. Therefore, fever alone is not a specific indicator of pain post-pyloromyotomy.
C. Restlessness or increased agitation can indicate pain in infants. They may squirm, move their arms and legs, or have difficulty settling down. Restlessness is a non-verbal cue that infants use to communicate discomfort or distress.
D. Peripheral pallor could indicate decreased peripheral perfusion, which might occur due to various factors post-operatively, but it is not a direct indicator of pain.
E. Increased respiratory rate can be associated with pain.
F. An increased pulse rate (tachycardia) is a physiological response to pain in infants. Pain activates the sympathetic nervous system, leading to an increased heart rate as the body prepares to respond to stress or discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. This comment suggests that the client is aware of the correct technique (inhaling and holding breath) but finds it difficult to execute properly. It indicates a partial understanding of the inhaler technique but potential difficulty in coordination.
B. This comment indicates a misunderstanding of the purpose of a rescue inhaler. Rescue inhalers are intended to be used promptly at the onset of symptoms to relieve acute shortness of breath. Delaying use until symptoms are severe may result in inadequate relief and worsening of respiratory distress.
C. This comment suggests that the client may be swallowing the medication instead of inhaling it into the lungs. Inhalers are meant to deliver medication directly into the lungs through inhalation, not swallowing. Swallowing the medication can lead to gastrointestinal side effects like nausea.
D. Shaking the inhaler before use is a correct step to ensure proper dispersion of the medication. This comment indicates the client understands and follows this part of the inhaler technique correctly.
Correct Answer is D
Explanation
Rationale
A. Iron-rich meats are beneficial for overall health, particularly for maintaining hemoglobin levels in the blood. However, they are not specifically known for their role in preventing osteoporosis. Iron is important for transporting oxygen in the blood but does not directly impact bone health.
B. Fresh fruits and vegetables are excellent sources of vitamins, minerals, and antioxidants. They contribute to overall health and well-being but are not specifically known for their direct impact on bone health unless they are rich in certain nutrients like vitamin C (found in citrus fruits and peppers) and vitamin K (found in leafy greens like spinach and kale), which can indirectly support bone health.
C. Water is essential for overall hydration and health, but it does not provide specific nutrients directly beneficial for bone health. Herbal teas can contribute to hydration and provide some antioxidant benefits, but they do not have a direct impact on osteoporosis prevention.
D. Low-fat dairy products such as milk, yogurt, and cheese are rich sources of calcium and vitamin D, which are crucial for bone health. Calcium is a primary mineral in bones, and vitamin D helps the body absorb calcium. These nutrients are essential for maintaining bone density and strength, thereby reducing the risk of osteoporosis.
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