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 B
Explanation
Choice A Reason:
The child exhibits a gag reflex when stimulated with a tongue blade. The gag reflex involves the glossopharyngeal nerve (cranial nerve IX) and vagus nerve (cranial nerve X), not the trigeminal nerve.
Choice B Reason:
The child has symmetrical jaw strength when biting down is correct. This finding indicates proper functioning of the child's trigeminal nerve. Symmetrical jaw strength when biting down suggests that both sides of the jaw muscles, which are innervated by the trigeminal nerve, are functioning equally and appropriately.
Choice C Reason:
The child maintains balance when standing with eyes closed is incorrect. This assessment involves the vestibular system and coordination, which are primarily associated with the vestibulocochlear nerve (cranial nerve VIII), not the trigeminal nerve.
Choice D Reason:
The child correctly identifies specific scents is incorrect. The olfactory nerve (cranial nerve I) is responsible for the sense of smell, not the trigeminal nerve.
Correct Answer is D
Explanation
Choice A Reason:
Inserting an IV is not typically required for this specific test. The test involves applying a substance (pilocarpine) to the skin to stimulate sweat production in a localized area for sweat collection.
Choice B Reason:
Measuring protein in the urine over a 24-hour period is unrelated to the pilocarpine iontophoresis test for cystic fibrosis. Protein measurement in urine over a 24-hour period is a different diagnostic test used for various conditions, but not for cystic fibrosis diagnosis.
Choice C Reason:
Fasting for 8 hours prior to the test is not necessary for the pilocarpine iontophoresis test. There's no requirement for fasting before this particular test.
Choice D Reason:
"The test will measure the amount of chloride in your baby's sweat." Is correct. Pilocarpine iontophoresis testing is a diagnostic test used to measure the concentration of chloride in a person's sweat. Elevated chloride levels in sweat are a hallmark of cystic fibrosis, so this test helps in the diagnosis of the condition.
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