Hesi RN Exit Proctored Exam
Select All That Apply
The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.
Explanation & Rationale
A. Clenched fists can indicate discomfort or pain in infants, suggesting the need for pain management. B. Restlessness is often a sign of pain or discomfort in infants and requires assessment for pain relief. C. Peripheral pallor can indicate other issues such as shock or anemia but is not a direct indicator of pain. D. An increased respiratory rate can be a response to pain or distress, indicating the child may need pain medication. E. An increased temperature could indicate infection or inflammation, but it is not a direct indicator of pain requiring medication. F. An increased pulse rate may indicate pain or anxiety and should be considered in the context of the child's overall assessment.
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