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?

Correct answer: D

A.Sharing a client's substance use information with their employer without their consent may violate confidentiality and privacy laws.

B.Sharing information about a client's suicide with another nurse may be appropriate for staff who need to know for safety reasons but should be done carefully and only with those who have a legitimate need for the information.

C.Sharing a client's medical information with their partner in this scenario may be appropriate under certain circumstances. However, it's essential to consider the client's safety and well-being first. If the client has reported intimate partner abuse, the nurse must assess the risk of harm to the client if their partner is informed. Depending on the situation, it may be necessary to involve other healthcare professionals, such as social workers or law enforcement, to ensure the client's safety. Before sharing any information with the partner, the nurse should follow institutional policies and legal requirements, which often involve obtaining the client's consent or assessing the potential harm of disclosure.

D.Sharing a client's medical information with a social worker who is directly involved in the client's care is generally appropriate and often necessary for effective interdisciplinary collaboration. In this scenario, the social worker is assigned to the client and is likely involved in coordinating the client's care and support services. Sharing relevant medical information with the social worker can facilitate continuity of care and help ensure that the client's needs are met appropriately. However, it's essential for the nurse to adhere to confidentiality requirements and only share information on a need-to-know basis, ensuring that the information is used for the purpose of providing care and support to the client.

Choice A Reason:

Maintaining the client in high-Fowler's position is a correct action. Keeping the client in a high-Fowler's position (sitting up with the head of the bed elevated) can help improve lung expansion and ease breathing for clients with heart failure and respiratory distress.

Choice B Reason:

Instructing the client to cough every 4 hr. is not directly addressing the underlying issue of fluid accumulation and respiratory distress associated with heart failure. Coughing alone may not be sufficient to alleviate these symptoms.

Choice C Reason:

Increasing the client's intake of oral fluids is generally not recommended without considering the client's overall fluid status. In heart failure, there is often a need to restrict fluid intake to prevent fluid overload and worsening of symptoms. Increasing oral fluids should be done cautiously and under the guidance of the healthcare provider.

Choice D Reason:

Encouraging the client to ambulate to loosen secretions. While ambulation can be beneficial for some clients to improve overall circulation and prevent complications, it may not be the primary intervention in this case. The client's primary issue is likely related to pulmonary congestion due to heart failure, and they may be too short of breath to ambulate effectively.