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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: A cool mist humidifier may help croup but is inadequate for a child with a barking cough, fever, and cyanosis (blue around the mouth), indicating severe respiratory distress. Immediate ER evaluation is critical, making this insufficient and incorrect for the urgent symptoms described in the scenario.

Choice B reason: A barking cough, fever, and cyanosis suggest severe croup or airway obstruction, requiring urgent medical evaluation. Bringing the child to the ER immediately ensures timely intervention for potential respiratory compromise, aligning with pediatric emergency protocols, making it the correct recommendation for the caregiver.

Choice C reason: Cold air exposure may temporarily relieve croup but is unsafe for a cyanotic child with fever, indicating severe distress. Immediate ER care is needed to address potential airway issues, making this risky and incorrect for managing the child’s critical symptoms in this urgent situation.

Choice D reason: Steam may help mild croup but delays care for a child with cyanosis, signaling severe respiratory compromise. Immediate ER evaluation is essential to prevent deterioration, making this inadequate and incorrect compared to the urgent need for professional assessment in the emergency department.

A. An interesting texture. B. Well-heated. C. Bland. D. Thickened.

Correct Answer is C

Explanation

Choice A reason: Interesting textures may intrigue older infants but can overwhelm new eaters, risking rejection. Bland foods are better tolerated initially, making this less suitable and incorrect compared to the nurse’s focus on foods infants accept best when introducing solids in the class.

Choice B reason: Well-heated foods risk burns and aren’t preferred by infants, who tolerate room-temperature or slightly warm foods. Bland flavors are more acceptable, making this incorrect, as it doesn’t address the taste preference infants respond to best when starting solid foods in the diet.

Choice C reason: Bland foods are gentle on infants’ sensitive palates, encouraging acceptance when introducing solids. This aligns with pediatric nutrition guidelines for transitioning diets, making it the correct factor for the nurse to highlight in teaching parents about starting solid foods for infants.

Choice D reason: Thickened foods may pose choking risks or be hard to swallow for new eaters. Bland foods are more readily accepted, making this incorrect, as it doesn’t prioritize the flavor profile infants respond to best when introducing solid foods in the parent education class.

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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)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is preparing to teach a class to a group of young parents with infants the basics of introducing solid foods into the diet. Which factor about the food should the nurse point out the infants respond to best when introducing solid foods into the diet?

Correct Answer is C

Explanation

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