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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.

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Correct Answer is D

Explanation

Rationale

A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.

B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.

C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.

D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.

A. Ask the most experienced UAP on the team to partner with the newly hired UAP. B. Assign the newly hired UAP to clients who require the least complex level of care. C. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care. D. Review the UAP's skills checklist and experience with the person who hired the UAP.

Correct Answer is A

Explanation

Rationale

A. Pairing the newly hired UAP with the most experienced UAP can provide mentoring and guidance. This allows the experienced UAP to share knowledge, demonstrate best practices, and help the new UAP navigate unfamiliar situations or complex care needs. It promotes skill development and ensures that care is provided effectively and safely.

B. Assigning less complex clients to the newly hired UAP initially can help ease them into their role and build confidence. It allows them to focus on learning routines, policies, and procedures without the added stress of managing highly complex care situations. However, this approach should be temporary and paired with opportunities for training and skill development.

C. Direct observation of the newly hired UAP's care delivery is crucial to assess their competency in various tasks. It provides firsthand insight into their skills, adherence to protocols, and ability to handle

client needs independently. Based on observations, appropriate feedback and additional training can be provided as needed.

D. Reviewing the UAP's skills checklist and discussing their previous experience with the hiring manager or supervisor provides essential background information. This helps in understanding the UAP's strengths, areas for improvement, and any specific training needs. It ensures that appropriate assignments and support are provided based on their skill level.

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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

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Correct Answer is A

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