Try Naxlex NCLEX-RN (Free-Trial)

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

Clenched fists.

Increased temperature.

Restlessness.

Peripheral pallor of the skin.

E Increased respiratory rate.

Increased pulse rate.

Answer and Explanation

Correct Answer : A,C,E,F

Rationale

A. Clenched fists can be a sign of pain in infants. Infants may reflexively clench their fists as a response to discomfort or pain. This behavior is commonly observed during painful procedures or when experiencing pain.

B. While fever can sometimes accompany pain due to inflammation or stress response, it is not typically a reliable indicator of pain in the absence of other signs. Therefore, fever alone is not a specific indicator of pain post-pyloromyotomy.

C. Restlessness or increased agitation can indicate pain in infants. They may squirm, move their arms and legs, or have difficulty settling down. Restlessness is a non-verbal cue that infants use to communicate discomfort or distress.

D. Peripheral pallor could indicate decreased peripheral perfusion, which might occur due to various factors post-operatively, but it is not a direct indicator of pain.

E. Increased respiratory rate can be associated with pain.

F. An increased pulse rate (tachycardia) is a physiological response to pain in infants. Pain activates the sympathetic nervous system, leading to an increased heart rate as the body prepares to respond to stress or discomfort.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale

A. While ensuring the room is secure and providing one-on-one observation are also important, the immediate concern after administering haloperidol is the potential for these side effects.

B. Continuous observation is crucial to monitor the client's behavior, mood, and safety while in seclusion. This allows the nurse to intervene promptly. However, monitoring should be specific

C. Seclusion is not intended as a punishment but as a therapeutic intervention to protect the client and others from harm during acute psychiatric episodes. The decision to release the client should be based on clinical assessment

D. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), including dystonia (muscle spasms). Monitoring for EPS is essential after administering haloperidol to ensure early detection and treatment, which may involve administering anticholinergic medications if EPS occurs.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse recognizes that this client is Hemorrhaging due to uterine atony.

Rationale

This client is likely experiencing hemorrhaging, as indicated by the boggy fundus (uterine atony), saturated pad and sheets with blood, and the significant estimated blood loss of 600 mL after delivery. Hemorrhaging refers to excessive bleeding, which can occur due to various reasons in the postpartum period, including uterine atony.

The boggy fundus (uterus) at 1 cm above the umbilicus suggests poor uterine tone, which is indicative of uterine atony. Uterine atony is a common cause of postpartum hemorrhage and occurs when the uterus fails to contract adequately after delivery, leading to excessive bleeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse has reviewed the client's chart. Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that this client is dropdown due to dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.