A nurse in an acute care facility is collecting data from a client who has received the meningococcal conjugate vaccine.
The nurse should monitor the client for which of the following findings as an adverse effect of the vaccine?

Choice A rationale:

Dry mouth is a common side effect of diphenhydramine. Diphenhydramine is an antihistamine that is often used to treat allergies, insomnia, and symptoms of the common cold. It works by blocking the effects of histamine, a substance in the body that causes allergy symptoms. One of the effects of histamine is increased salivation, so when diphenhydramine blocks this effect, it can lead to dry mouth.

Choice B rationale:

Nausea is also a common side effect of diphenhydramine. This can occur because diphenhydramine can slow down the emptying of the stomach, leading to feelings of nausea. Additionally, diphenhydramine can affect the vestibular system in the inner ear, which can also lead to feelings of nausea.

Choice C rationale:

Agitation is considered an idiosyncratic reaction to diphenhydramine. An idiosyncratic reaction is an unusual or unexpected reaction to a drug that is not related to the usual pharmacological action of the drug. While diphenhydramine is typically used for its sedative effects, in some cases it can cause paradoxical central nervous system stimulation, leading to agitation.

Choice D rationale:

Dizziness is another common side effect of diphenhydramine. This occurs because diphenhydramine can affect the vestibular system in the inner ear, which plays a key role in maintaining balance. When this system is affected, it can lead to feelings of dizziness.

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.