When evaluating a terminally ill client for pain relief following medication administration, which nursing assessments would be documented to support that the medication was effective? (Select all that apply)
Heart rate and respirations are within normal limits.
The child is withdrawing from the environment.
The client is lying in a flexed position on the bed.
The client verbalizes a 1 on the analog pain scale.
The client is quietly sleeping on the parent’s lap.
Correct Answer : A,D,E
Choice A reason: Normal heart rate and respirations indicate reduced physiological stress from pain, supporting effective medication in a terminally ill child. This aligns with pediatric pain assessment criteria, making it a correct assessment to document as evidence of successful pain relief post-medication administration.
Choice B reason: Withdrawing from the environment suggests ongoing distress or pain, not relief. Normal vitals and low pain scores indicate effectiveness, making this incorrect, as it reflects a negative outcome rather than supporting successful pain management in the terminally ill child’s evaluation.
Choice C reason: A flexed position may indicate persistent pain or discomfort, not relief. Sleeping or low pain scores better demonstrate effectiveness, making this incorrect, as it does not support the medication’s success in alleviating pain in the terminally ill client during the assessment.
Choice D reason: Verbalizing a 1 on the pain scale directly indicates minimal pain, confirming the medication’s effectiveness in a terminally ill child. This aligns with pediatric pain management standards, making it a correct assessment to document as evidence of successful pain relief post-administration.
Choice E reason: Quietly sleeping on the parent’s lap suggests comfort and pain relief, a positive sign in a terminally ill child. This aligns with behavioral pain assessment in pediatrics, making it a correct observation to document as evidence of effective medication for pain management.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Vitamin E is not typically deficient in evaporated milk formulas, and supplementation is not standard. Vitamin D is critical to prevent rickets in infants, making this incorrect, as it does not address the primary nutritional gap in homemade evaporated milk formulas for an 8-month-old.
Choice B reason: Evaporated milk lacks sufficient vitamin D, essential for calcium absorption and bone health in an 8-month-old. Ensuring vitamin D supplementation prevents rickets, aligning with pediatric nutrition guidelines, making it the correct ingredient to include in the infant’s homemade formula diet.
Choice C reason: Iron is important but less critical in evaporated milk, which retains some iron, and infants have stores until 6 months. Vitamin D is the primary deficiency, making this incorrect compared to addressing the urgent need for vitamin D in the 8-month-old’s formula.
Choice D reason: Evaporated milk contains adequate calcium, unlike vitamin D, which is deficient and critical for bone development. Ensuring vitamin D inclusion is prioritized, making this incorrect, as calcium supplementation is not the primary concern in the infant’s evaporated milk formula diet.
Correct Answer is D
Explanation
Choice A reason: Weighing the child monitors fluid retention but is less urgent than blood pressure, which assesses hypertensive encephalopathy risk post-convulsion in glomerulonephritis. Immediate blood pressure data guides treatment, making this secondary and incorrect compared to evaluating the child’s neurological status after a seizure.
Choice B reason: Giving fluids without guidance risks worsening fluid overload in glomerulonephritis, and delayed reporting is unsafe post-convulsion. Blood pressure assessment is critical, making this inappropriate and incorrect compared to the urgent need for immediate data to address the child’s seizure episode effectively.
Choice C reason: Administering a diuretic without provider orders is unsafe post-convulsion, as it may not address the seizure’s cause. Blood pressure evaluation informs treatment, making this risky and incorrect compared to the priority of assessing hypertension in the child with glomerulonephritis immediately.
Choice D reason: Taking blood pressure post-convulsion assesses for hypertension, a common seizure cause in glomerulonephritis, guiding urgent treatment. Reporting immediately ensures timely intervention, aligning with pediatric nephrology protocols, making this the correct action for the caregiver to take in this emergency situation.
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