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?

The correct answer is choice B. Nontender, protruding abdomen.

Choice A rationale:

Natural loss of deciduous teeth typically begins around the age of 6 years, not at 2 years. At 2 years old, toddlers are still in the process of getting their primary teeth.

Choice B rationale:

A nontender, protruding abdomen is a normal finding in toddlers due to their developing abdominal muscles and the typical posture of a toddler.

Choice C rationale:

By the age of 2, a child’s head circumference should no longer exceed their chest circumference. This is a characteristic of infants, not toddlers.

Choice D rationale:

Palpable fontanels are expected in infants. By the age of 2, the anterior fontanel should have closed, making it non-palpable.

Choice A reason:

Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.

Choice B reason:

Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.

Choice C reason:

Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.

Choice D reason:

The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.