The nurse prioritizes which infant to administer pain medication to first? All have PRN (as needed) orders for pain medication.
A 12-month-old who is 2-days post-op cleft palate repair whose vital signs are within normal limits
A 6-month-old who is crying and becomes calm when held by a parent
An 8-month-old with legs drawn to chest and a temperature of 39.5 degrees C
A 4-month-old that has just returned from the recovery room
The Correct Answer is C
Choice A reason: This statement is false. A 12-month-old who is 2-days post-op cleft palate repair whose vital signs are within normal limits is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be mild and manageable with non-pharmacological interventions, such as distraction, comfort, or oral care.
Choice B reason: This statement is false. A 6-month-old who is crying and becomes calm when held by a parent is not the priority for pain medication. This infant may have some pain from an unknown cause, but it is likely to be transient and responsive to non-pharmacological interventions, such as soothing, rocking, or cuddling.
Choice C reason: This statement is true. An 8-month-old with legs drawn to chest and a temperature of 39.5 degrees C is the priority for pain medication. This infant may have severe pain from an infection, such as appendicitis, meningitis, or urinary tract infection. This infant may also have signs of inflammation, such as fever, leukocytosis, or elevated C-reactive protein. This infant needs immediate pain relief and antibiotic therapy.
Choice D reason: This statement is false. A 4-month-old that has just returned from the recovery room is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be moderate and controlled with pharmacological interventions, such as opioids, NSAIDs, or local anesthetics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Cushing's syndrome is caused by excess cortisol, a type of glucocorticoid hormone, in the body. This can result from overproduction of cortisol by the adrenal glands, or from prolonged use of corticosteroid medications. Elevated glucocorticoid level is the correct alteration in endocrine function for this condition.
Choice B reason: Decreased aldosterone level is not related to Cushing's syndrome. Aldosterone is another hormone produced by the adrenal glands, but it regulates the balance of sodium and potassium in the body. Decreased aldosterone level can cause low blood pressure, dehydration, and electrolyte imbalance.
Choice C reason: Elevated aldosterone secretion is also not related to Cushing's syndrome. Elevated aldosterone secretion can cause high blood pressure, fluid retention, and hypokalemia (low potassium level). This condition is known as hyperaldosteronism or Conn's syndrome.
Choice D reason: Diminished glucocorticoid level is the opposite of Cushing's syndrome. Diminished glucocorticoid level can cause low blood sugar, fatigue, weight loss, and poor stress response. This condition is known as Addison's disease or adrenal insufficiency.
Correct Answer is C
Explanation
Choice A reason: A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain is not the most urgent patient to assess. Peripheral neuropathy is a complication of diabetes that affects the nerves, especially in the feet and legs. It can cause symptoms such as numbness, tingling, burning, or pain. The nurse should assess the patient's foot condition, provide pain relief, and educate the patient on foot care. However, this patient is not in immediate danger, and can wait until the nurse finishes assessing the more critical patient.
Choice B reason: A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL is not the most critical patient to assess. Type 1 diabetes is a condition where the pancreas does not produce any insulin, a hormone that helps the cells use glucose for energy. Patients with type 1 diabetes need to take insulin injections or use an insulin pump to control their blood glucose level. A blood glucose reading of 230 mg/dL is above the normal range of 70 to 130 mg/dL before meals, and indicates hyperglycemia (high blood sugar). The nurse should check the patient's insulin dose, monitor the patient's symptoms, and provide education on blood glucose management. However, this patient is not in life-threatening condition, and can wait until the nurse attends to the more serious patient.
Choice C reason: A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output is the most important patient to assess. Hyperosmolar hyperglycemic syndrome (HHS) is a severe complication of diabetes that occurs when the blood glucose level is extremely high, usually above 600 mg/dL. HHS can cause dehydration, electrolyte imbalance, and coma. Dry oral mucosa and low urine output are signs of dehydration, which can lead to shock and organ failure. The nurse should assess the patient's vital signs, blood glucose level, fluid and electrolyte status, and neurological function. The nurse should also administer intravenous fluids, insulin, and electrolytes as prescribed by the health care provider. This patient is in a medical emergency, and needs immediate intervention.
Choice D reason: A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon is not the most acute patient to assess. Dawn phenomenon is a condition where the blood glucose level rises in the early morning, usually between 2:00 AM and 8:00 AM. This is due to the release of hormones that increase the blood glucose level, such as growth hormone, cortisol, and glucagon. The nurse should review the patient's blood glucose records, adjust the insulin dose or timing, and provide education on how to prevent or manage the dawn phenomenon. However, this patient is not in a critical situation, and can wait until the nurse evaluates the more unstable patient.
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