A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.
Which of the following findings would indicate a need for pain medication? Select all that apply.
Increased pulse rate.
Skin showing peripheral pallor.
Clenched fists.
Increased respiratory rate.
Restlessness.
Elevated temperature.
Correct Answer : A,C,D,E,F
Choice A rationale
An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.
Choice B rationale
Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.
Choice C rationale
Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.
Choice D rationale
An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.
Choice E rationale
Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.
Choice F rationale
An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
Correct Answer is B
Explanation
Choice A rationale
Resuming normal physical activity is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of Diabetic Ketoacidosis (DKA). Physical activity can increase blood glucose levels, which could exacerbate the condition.
Choice B rationale
Administering a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a patient with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.
Choice C rationale
Consuming electrolyte fluid replacements is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While hydration is important, it does not address the underlying issue of high blood sugar levels.
Choice D rationale
Monitoring urine output over the next 24 hours is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While it is important to monitor urine output in patients with diabetes, it does not address the underlying issue of high blood sugar levels.
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