The practical nurse (PN) is assessing an infant the first postoperative day following a pylorotomy. The infant was medicated for pain one hour ago, but the PN does not believe that the medication is effective. Which finding(s) indicate that the infant is still experiencing pain and that the analgesia was not effective? Select all that apply.
Pulse rate 102.
Facial grimaces.
Knees drawn to chest.
Restlessness.
Temperature 98.6° F (37.0° C).
Correct Answer : B,C,D
A. Pulse rate 102:This is actually a normal heart rate for an infant (the typical range is 100 to 160 beats per minute). Pain usually causes tachycardia. If the infant were in significant pain, you would expect a heart rate much higher than 102.
B. Facial grimaces: In infants, facial grimacing, a furrowed brow, or chin quivering are among the most reliable behavioral indicators of pain.
C. Knees drawn to chest: Drawing the knees up to the chest is a classic behavioral sign of abdominal pain or distress in an infant, especially following abdominal surgery like a pylorotomy.
D. Restlessness: Restlessness, irritability, and the inability to be easily consoled are common signs that an infant's pain is not well-controlled.
E. Temperature 98.6° F (37.0° C): This is a normal body temperature. While a fever can sometimes be associated with the inflammatory response or infection, it is not used as a clinical indicator to assess the immediate effectiveness of an analgesic for acute postoperative pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Instruct team members to ignore the client's hallucinations: Incorrect; ignoring can increase anxiety; therapeutic acknowledgment is needed.
B. Acknowledge that the client's perception is not real to others: Validates feelings without reinforcing hallucinations, helps maintain reality orientation.
C. Instruct the client to stop scaring the other clients: Confrontational and non-therapeutic.
D. Offer support and reassure the client that he is in a safe place: Reduces anxiety and builds trust.
E. Use simple commands in a calm, soothing voice: Helps with comprehension and reduces agitation.
F. Restrict the client to his room and apply soft wrist restraints: Only used if there is immediate danger to self/others; not indicated here.
Correct Answer is D
Explanation
A. Consensual pupillary constriction present: This refers to both pupils constricting when light is shone in one eye, not accommodation.
B. Peripheral vision intact: Not related to this assessment; peripheral vision testing uses confrontation method.
C. Nystagmus present with pupillary focus: Nystagmus is involuntary eye movement, unrelated to accommodation response.
D. Pupils reactive to accommodation: This describes normal constriction when focusing on near objects after focusing on distant ones.
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