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?
Limb withdrawal.
Relaxed facial expression.
Increased blood pressure.
Bradycardia.
The Correct Answer is B
Choice A rationale:
Limb withdrawal is a pain response and indicates that the infant is experiencing pain. The goal of opioid pain medication is to alleviate pain, so limb withdrawal suggests inadequate pain control.
Choice B rationale:
A relaxed facial expression indicates that the infant is comfortable and not experiencing pain. It is a positive sign that the medication is having a therapeutic effect by providing pain relief.
Choice C rationale:
Increased blood pressure is not a typical response to opioid pain medication. Opioids often cause a decrease in blood pressure and can lead to hypotension.
Choice D rationale:
Bradycardia (slow heart rate) is not a common response to opioid pain medication. Opioids can cause respiratory depression and bradypnea (slow breathing), but they do not typically cause bradycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
Choice A rationale:
The sleeping pattern is mentioned, but it does not provide relevant information regarding the infant's condition. The fact that the infant is sleeping through the night does not address the concerns related to gastroesophageal reflux.
Choice B rationale:
Irritability is mentioned in the notes, but it is not a parameter that directly reflects the improvement or worsening of the infant's condition. While irritability can be a symptom of discomfort due to reflux, it's not a parameter to monitor progress over time.
Choice C rationale:
Monitoring the infant's weight is crucial in this scenario. Weight gain is a significant indicator of the infant's overall health and nutritional status. A decrease in weight gain could indicate feeding difficulties or other health issues. In this case, the weight has increased, suggesting improvement in the infant's condition.
Choice D rationale:
Regurgitation is one of the main symptoms of gastroesophageal reflux. Monitoring the frequency and severity of regurgitation is essential to assess the effectiveness of interventions, such as thickened feedings. The persistence of regurgitation in this case indicates that the condition has not completely resolved.
Choice E rationale:
Heart rate is not mentioned in the provided information, and it does not provide relevant information about the infant's condition in this context.
Choice F rationale:
Bottle feeding is mentioned, specifically the thickening of feedings. This information is crucial in assessing the effectiveness of interventions for gastroesophageal reflux. Thickened feedings are often recommended to reduce regurgitation, and the fact that the parents have been thickening the feedings suggests an attempt to manage the condition.
Correct Answer is C
Explanation
Choice A rationale:
Providing a high-calorie, low-protein diet is not directly related to the management of osteomyelitis. However, proper nutrition is essential for overall healing and immune function.
Choice B rationale:
Encouraging frequent physical activity to increase bone mass is not appropriate for a child with osteomyelitis. Physical activity can worsen the condition and cause further damage to the affected bone.
Choice C rationale:
Maintaining a patent intravenous catheter is important for administering intravenous antibiotics, which are the mainstay of treatment for osteomyelitis. Ensuring that the catheter is functional and infection-free is crucial for the delivery of appropriate antibiotics to combat the infection.
Choice D rationale:
Initiating contact precautions is not necessary for osteomyelitis. Osteomyelitis is not typically spread through direct contact but results from the spread of bacteria through the bloodstream to the affected bone.
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