A client has been receiving the same dose of IV opiate for 2 days to manage post-surgical pain. The client reports the drug is no longer controlling the pain. What does the nurse suspect?
Tolerance to the opiate medication is developing
There is likely a history of addiction
The client is opiate naive
Physical dependence
The Correct Answer is A
Choice A rationale:
Tolerance to the opiate medication is developing. This is the most likely explanation for why the client's pain is no longer being controlled by the same dose of medication. Tolerance is a physiological adaptation that occurs with repeated exposure to opioids, leading to a decrease in their effectiveness over time. This means that the client's body is becoming less responsive to the medication, and a higher dose is needed to achieve the same level of pain relief.
Choice B rationale:
There is likely a history of addiction. While it is possible that the client has a history of addiction, this is not the most likely explanation for why the medication is no longer controlling the pain. Addiction is a complex condition that is characterized by compulsive drug seeking and use, despite negative consequences. It is not simply a matter of tolerance developing.
Choice C rationale:
The client is opiate naive. This means that the client has not previously been exposed to opioids. While opiate-naive clients may be more sensitive to the effects of opioids, they are also more likely to experience side effects, such as nausea and vomiting. The fact that the client has been receiving the same dose of medication for 2 days without experiencing side effects suggests that they are not opiate naive.
Choice D rationale:
Physical dependence. Physical dependence is a state of adaptation that occurs with repeated exposure to opioids, leading to withdrawal symptoms if the medication is abruptly stopped. However, physical dependence does not necessarily mean that the medication is no longer effective in controlling pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale for Choice A:
Documenting and continuing to monitor is a crucial aspect of nursing care; however, in this scenario, it would not be the first action to take. The significant drop in blood pressure warrants immediate intervention to prevent potential complications.
While monitoring is essential, it does not actively address the underlying cause of the hypotension. Relying solely on monitoring could delay necessary interventions and potentially compromise patient safety.
It's important to balance monitoring with timely interventions to ensure optimal patient outcomes. In this case, calling for assistance takes priority over documentation and continued monitoring.
Rationale for Choice B:
Repeating the blood pressure in 15 minutes could delay critical interventions if the hypotension is severe. Timely action is crucial to maintain adequate tissue perfusion and prevent organ damage.
Waiting to recheck the blood pressure could potentially worsen the patient's condition and lead to adverse outcomes. It's essential to act promptly when a significant change in vital signs occurs.
Rationale for Choice D:
While notifying the primary healthcare provider is an important step, it may not be the most immediate action in this situation. The Rapid Response Team is specifically trained to handle acute patient deterioration and can provide timely interventions.
The Rapid Response Team can initiate life-saving measures, such as administering fluids or medications, while the primary healthcare provider is being notified. This ensures that the patient receives prompt and appropriate care.
Rationale for Choice C:
Calling the Rapid Response Team is the most appropriate first action in this scenario because it ensures a rapid and coordinated response to the patient's hypotension.
The Rapid Response Team can quickly assess the patient, initiate interventions, and potentially prevent further complications. They can also facilitate communication and collaboration among healthcare providers.
Early activation of the Rapid Response Team has been shown to improve patient outcomes in various clinical settings, including postoperative care.
Correct Answer is D
Explanation
Rationale for Choice A:
Hydroxychloroquine does not typically cause hair loss as a significant side effect. While some anecdotal reports have suggested hair thinning as a possibility, it's not a well-established or common occurrence in clinical studies.
If a patient experiences hair loss while on hydroxychloroquine, it's essential to rule out other potential causes, such as underlying medical conditions, stress, or nutritional deficiencies.
It's also important to note that some individuals may have a personal predisposition to hair loss, and medications can sometimes trigger or exacerbate this issue.
Rationale for Choice B:
Hydroxychloroquine is not known to cause a burst of energy. In fact, some patients may experience fatigue or drowsiness as a side effect.
It's crucial to inform patients about potential side effects to manage expectations and promote adherence to treatment.
If a patient experiences unexpected energy changes while taking hydroxychloroquine, it's essential to report this to their healthcare provider for further evaluation.
Rationale for Choice C:
Hydroxychloroquine is generally recommended to be taken with food or milk to reduce potential gastrointestinal side effects such as nausea and vomiting.
Taking it on an empty stomach could increase the risk of these side effects, which could impact medication adherence and effectiveness.
Rationale for Choice D:
Retinal damage is the most serious adverse effect of hydroxychloroquine. It can lead to irreversible vision loss if not detected and managed early.
Patients taking hydroxychloroquine must undergo regular eye examinations to monitor for any signs of retinal toxicity.
Early detection and prompt discontinuation of the medication can often prevent permanent vision loss.
It's crucial for nurses to educate patients about this potential risk and emphasize the importance of regular eye exams.
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