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","C"]
Explanation
Choice A Reason:
Transfer a client who is receiving radiation therapy to radiology is not appropriate .Transferring a client receiving radiation therapy may involve specific safety considerations and precautions that should be performed by a healthcare professional with appropriate training.
Choice B Reason:
Measure vital signs for a client who requires contact precautions is appropriate. Measuring vital signs, such as taking temperature, blood pressure, heart rate, and respiratory rate, is a routine task that can be safely delegated to an AP.
Choice C Reason:
Record urine output for a client who has a suprapubic catheter is appropriate. Recording urine output is a straightforward task that can be delegated to an AP, provided they are trained in the proper technique for measuring and documenting urine output
Choice D Reason:
Plan care for a client who has dysphagia is incorrect. Planning care for a client with dysphagia involves assessment, evaluation, and coordination of care, which require the expertise of a licensed nurse or healthcare provider.
Correct Answer is C
Explanation
The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.
While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.
Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.
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