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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Client isolates themselves from their family and friends. Isolating oneself from family and friends is an indication that the client is experiencing a crisis. Social withdrawal and isolation can be common responses to severe anxiety or a crisis situation. It suggests that the client is having difficulty coping with their anxiety or the stressor, and they may benefit from intervention and support.
Choice B Reason:
Reporting intermittent depressed mood may be indicative of a mood disorder but does not necessarily indicate a crisis.
Choice C Reason:
Reporting a decreased appetite can be a symptom of anxiety, but it is not specific to a crisis situation.
Choice D Reason:
Expressing an inability to experience pleasure is a symptom often associated with depression but does not provide specific information about the presence of a crisis.
Correct Answer is A
Explanation
Choice A Reason:
"I would like to observe you using your glucometer. “To evaluate the client's use of a glucometer effectively, the nurse should ask the client to demonstrate how they use the device to check their blood glucose levels. This allows the nurse to directly observe the client's technique, including proper hand hygiene, fingerstick procedure, test strip insertion, and interpretation of results. It also provides an opportunity to correct any errors or misconceptions in real-time and ensure the client is using the glucometer correctly.
Choice B Reason:
"Show me what blood glucose supplies you have available." This question assesses the client's supply inventory but does not assess their actual use of the glucometer.
Choice C Reason:
"Let me demonstrate for you how to use this machine correctly." This option involves the nurse demonstrating the use of the glucometer to the client, which may be helpful as part of teaching but does not evaluate the client's current proficiency in using the device.
Choice D Reason:
"Tell me how long you have been using this glucometer." This question inquiries about the client's history of using the glucometer but does not assess their current competence in using it.
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