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 B
Explanation
Choice A Reason:
Recording blood glucose levels during a 24-hour creatinine clearance test is not typically necessary for this test. This test primarily measures kidney function, not blood glucose levels.
Choice B Reason:
"You can begin collection of urine after discarding your first morning void." When conducting a 24-hour creatinine clearance test, the client should begin the collection of urine after discarding their first morning void. This helps ensure that the urine collected during the test is a continuous sample that includes both daytime and nighttime urine output. The client should discard the first void of the day but then collect all urine voided for the next 24 hours, including the first void of the following morning.
Choice C Reason:
Eating a protein-rich diet during the collection period can affect the accuracy of the test results, as it may increase creatinine excretion. The client should follow the healthcare provider's instructions regarding dietary restrictions.
Choice D Reason:
Cleansing the perineal area with an antiseptic towel each time before voiding is not typically required for this test. It is more important to ensure that all urine is collected and that the collection container is stored properly to prevent contamination.
Correct Answer is D
Explanation
Choice A Reason:
Confronting the client regarding inappropriate behavior is not appropriate. Individuals with memory loss may exhibit behaviors that result from their cognitive impairment, and confrontation can lead to distress.
Choice B Reason:
Offering several meal options at lunchtime can be overwhelming for clients with memory loss. Simplifying choices and providing clear options are more effective strategies.
Choice C Reason:
Inadequate lighting can contribute to disorientation and falls. Well-lit areas with natural or soft lighting are preferable.
Choice D Reason:
Clients experiencing confusion and memory loss benefit from visual cues and simple, clear communication. Using symbols (such as pictures of a toilet for the restroom or a plate for the dining area) can help them navigate the environment more easily and reduce frustration.
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