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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Complying with a babysitter despite being upset shows adaptability, not initiative, which involves self-directed tasks. Attempting to clean cereal reflects proactive behavior, making this less indicative and incorrect compared to an activity demonstrating the 4-year-old’s initiative in the developmental assessment.
Choice B reason: Trying to sweep spilled cereal and crying when failing demonstrates initiative, as the 4-year-old independently attempts a task, a hallmark of Erikson’s initiative stage. This aligns with pediatric developmental milestones, making it the correct activity to document for assessing the child’s growth and development status.
Choice C reason: Refusing to hold hands while crossing the street indicates defiance, not initiative, which involves purposeful self-started activities. Cleaning cereal better reflects initiative, making this incorrect, as it shows autonomy rather than the proactive behavior expected in the initiative stage of development.
Choice D reason: Blaming a broken dish on a fictional friend shows guilt avoidance, not initiative, which involves taking on tasks independently. Attempting a cleanup task is more indicative, making this incorrect compared to the proactive behavior of sweeping cereal in the 4-year-old’s developmental assessment.
Correct Answer is C
Explanation
Choice A reason: Infant sebaceous and sweat glands are not fully functional, developing postnatally. The skin’s role in temperature regulation is accurate, making this incorrect, as it misstates infant integumentary function in the instructor’s presentation to student nurses on the system’s role.
Choice B reason: The integumentary system is present at birth, though maturing over time, not absent until after birth. Temperature regulation is a key function, making this incorrect, as it exaggerates the system’s developmental timeline in the instructor’s presentation on the integumentary system.
Choice C reason: The skin, the body’s largest organ, regulates temperature through sweating and vasodilation, a primary integumentary function. This aligns with physiological principles, making it the most accurate statement for the instructor to present to student nurses about the integumentary system’s role.
Choice D reason: Oxygen distribution is a respiratory and circulatory function, not integumentary. The skin’s temperature regulation is correct, making this incorrect, as it misattributes a role to the integumentary system in the instructor’s presentation to student nurses on its physiological functions.
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