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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.

Answer and Explanation

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.

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Correct Answer is ["C","D","E","F","G","H","J"]

Explanation

Based on the provided information, the following assessment findings require immediate follow-up by the nurse:

Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
The client is pale: Paleness can be a sign of decreased oxygenation.
Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.

A. Resume normal physical activity. B. Administer a dose of regular insulin as prescribed. C. Consume electrolyte fluid replacements. D. Monitor urine output over the next 24 hours.

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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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","E","F","G","H","J"]

Explanation

When educating a patient newly diagnosed with type 1 diabetes mellitus, the nurse explains that increased thirst is an early sign of Diabetic Ketoacidosis (DKA). What action should the nurse advise the patient to take if this sign of DKA appears?

Correct Answer is B

Explanation

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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.