A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
Sleepy, but arousing when her name is called.
Respiratory rate 8/min.
Pain level of 6 on a scale from 0 to 10.
The Correct Answer is B
Choice A reason:
Being sleepy but arousing when her name is called is a common side effect of morphine, which is a potent opioid analgesic. Morphine can cause drowsiness and sedation, but this is not necessarily an adverse effect unless it progresses to a state where the patient cannot be easily aroused. Therefore, while this is a side effect, it is not as concerning as respiratory depression.
Choice B reason:
A respiratory rate of 8/min is an adverse effect of morphine. Opioids like morphine can depress the respiratory center in the brain, leading to a decreased respiratory rate. Normal respiratory rates for adults are typically between 12 and 20 breaths per minute. A rate of 8 breaths per minute indicates significant respiratory depression, which can be life-threatening and requires immediate intervention.
Choice C reason:
A pain level of 6 on a scale from 0 to 10 indicates that the morphine has not fully alleviated the client’s pain. While this is important to address, it is not an adverse effect of the medication. The primary concern with morphine administration is monitoring for serious side effects like respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Using a kitchen spoon to administer the medication is not recommended. Kitchen spoons can vary in size and may not provide an accurate dose. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage.
Choice B reason: Written information about the medication is crucial for the parents or caregivers. This information should include the name of the medication, the dosage, the frequency of administration, and any special instructions. Providing written information helps ensure that the medication is administered correctly and consistently.
Choice C reason: The reason why the child is taking the medication should be clearly explained to the parents or caregivers. Understanding the purpose of the medication helps ensure compliance and allows them to monitor the child’s response to the treatment.
Choice D reason: The adverse effects of the medication should be discussed with the parents or caregivers. Knowing the potential side effects allows them to recognize and respond to any adverse reactions promptly. This information is essential for the safe administration of the medication.
Choice E reason: Stopping the medication when the child feels better is incorrect. Antibiotics should be taken for the full prescribed course, even if the child starts to feel better before the medication is finished. Stopping the medication early can lead to incomplete treatment of the infection and contribute to antibiotic resistance.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
The statement “Long attention span” is generally not associated with autism spectrum disorder (ASD). Children with ASD often have difficulty maintaining attention on tasks or activities, especially those that do not interest them. They may exhibit hyperfocus on specific interests but typically struggle with sustained attention in other areas.
Choice B reason:
The statement “Delayed language development” is a common characteristic of ASD. Many children with autism experience delays in speech and language skills. They may have difficulty with verbal communication, understanding language, and using language in social contexts. This delay can vary widely among individuals with ASD.
Choice C reason:
The statement “Speaking with direct eye contact” is not typically associated with ASD. Children with autism often avoid direct eye contact and may find it uncomfortable or overwhelming. They might look away or use peripheral vision instead of making direct eye contact during conversations.
Choice D reason:
The statement “Repetitive behavior” is a hallmark of ASD. Children with autism often engage in repetitive behaviors, such as hand-flapping, rocking, or repeating certain actions or phrases. These behaviors can be a way to self-soothe or cope with sensory overload.
Choice E reason:
The statement “Playing with toys repetitively” is also characteristic of ASD. Children with autism may play with toys in a repetitive manner, such as lining them up, spinning them, or focusing on specific parts of the toy rather than using them in imaginative play. This repetitive play is part of the broader pattern of repetitive behaviors seen in ASD.
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