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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Intention tremors are not typically associated with Addison’s disease. Intention tremors are more commonly seen in conditions affecting the cerebellum, such as multiple sclerosis or cerebellar ataxia.

Choice B reason: Purple striations (striae) are more commonly associated with Cushing’s syndrome, which is characterized by excessive cortisol levels. Addison’s disease, on the other hand, involves insufficient cortisol production.

Choice C reason: Hirsutism refers to excessive hair growth in women in areas where hair is normally minimal or absent. This condition is more commonly associated with polycystic ovary syndrome (PCOS) or other endocrine disorders, not Addison’s disease.

Choice D reason: Hyperpigmentation is a hallmark sign of Addison’s disease. It occurs due to increased production of melanocyte-stimulating hormone (MSH) as a byproduct of elevated adrenocorticotropic hormone (ACTH) levels. This leads to darkening of the skin, especially in areas exposed to friction, such as the elbows, knees, knuckles, and scars.

A. Explain the discharge instructions to the client and parents. B. Perform a neurovascular assessment. C. Provide reassurance to the client and parents. D. Apply an ice pack to the casted leg.

Correct Answer is B

Explanation

Choice A reason:

Explaining the discharge instructions to the client and parents is important for ensuring they understand how to care for the cast and recognize signs of complications. However, this is not the immediate priority. The primary concern should be assessing the client’s current condition to ensure there are no immediate risks, such as compromised circulation or nerve damage.

Choice B reason:

Performing a neurovascular assessment is the priority action. This assessment involves checking for circulation, movement, and sensation in the affected limb. It is crucial to identify any signs of neurovascular compromise, such as decreased blood flow or nerve damage, which can occur with a new cast. Early detection of these issues can prevent serious complications.

Choice C reason:

Providing reassurance to the client and parents is important for their emotional well-being and can help reduce anxiety. However, it is not the immediate priority. Ensuring the physical health and safety of the client through a neurovascular assessment takes precedence.

Choice D reason:

Applying an ice pack to the casted leg can help reduce swelling and pain, but it is not the immediate priority. The first step should be to assess the neurovascular status to ensure there are no urgent issues that need to be addressed.

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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?

Nursing Test Bank

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