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
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Correct Answer is D
Explanation
A. Would you like me to call another nurse to be here while I show you the wound?: May feel pressured; not supportive.
B. Part of recovery is accepting your new body image and you will need to look at your incision: Judgmental and may increase resistance.
C. You will feel better when you see that the incision is not as bad as you may think: Assumes feelings; not therapeutic.
D. It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready: Acknowledges client’s feelings and leaves door open for readiness.
Correct Answer is D
Explanation
A. Gargle with warm salt water: Helps sore throat but not most urgent.
B. Avoid exposing older client to complications: Not related to spleen risk.
C. Stay home and isolate for two weeks: Good infection control but not most critical.
D. Use stool softeners to prevent Valsalva maneuver: Valsalva increases intra-abdominal pressure and risk of splenic rupture.
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