A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Hypertension

Lacrimation

Tachycardia

Urinary retention

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Hypertension (high blood pressure) is not a common adverse effect of morphine. Opioid medications are more likely to cause hypotension (low blood pressure).

Choice B Reason:

Lacrimation (excessive tearing) is not a typical adverse effect of morphine. Opioids can cause dry mouth and decreased tear production.

Choice C Reason:

Tachycardia (rapid heart rate) is not a common adverse effect of morphine. Morphine and other opioids are more likely to cause bradycardia (slow heart rate) or a decrease in heart rate.

Choice D Reason:

Urinary retention is an adverse effect associated with opioid medications like morphine. Opioids can cause relaxation of smooth muscles, including those in the urinary bladder, which can lead to difficulty or inability to urinate.

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Correct Answer is A

Explanation

Choice A Reason:

Encourage the client to be assertive. One of the goals in managing a client with dependent personality disorder is to gradually increase their independence and self-confidence. Encouraging the client to be more assertive and make decisions for themselves, with appropriate guidance and support, can be beneficial in their long-term recovery. However, it should be done gradually and with the assistance of therapy and counseling. The other options are not appropriate:

Choice B Reason:

Assuming responsibility for making the client’s, decisions would not help the client develop independence and could perpetuate their dependency.

Choice C Reason:

Maintaining a verbal no-harm contract is not specifically related to managing dependent personality disorder. It might be relevant for clients with suicidal ideation or self-harm tendencies, but it's not a primary intervention for this condition.

Choice D Reason:

Limiting the client's social interactions is not a recommended approach. Encouraging healthy social interactions and relationships can be beneficial for clients with dependent personality disorder, as long as they are appropriate and not reinforcing dependency. Explanation

A. Ecchymosis on the inner left thigh B. One fingerbreadth of space between the cast and the skin C. Diminished pulses on the aﬀected extremity D. Client report of muscle spasms of the left leg

Correct Answer is C

Explanation

c. Diminished pulses on the aﬀected extremity. This finding may indicate compromised circulation, which is

a serious complication that requires immediate intervention.

Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.

Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.

Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may

be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the aﬀected extremity.

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A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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