A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?
Prolonged QT interval
Fluid retention
Bradypnea
Hyperactive deep tendon reflexes
The Correct Answer is C
Rationale:
A. Prolonged QT interval: This is not a typical sign of morphine toxicity. QT prolongation is more commonly associated with certain antipsychotics, antiarrhythmics, or methadone, not opioids like morphine.
B. Fluid retention: Morphine does not typically cause fluid retention. While it may contribute to urinary retention, generalized fluid accumulation is not characteristic of opioid toxicity and may point to other causes like heart or renal failure.
C. Bradypnea: Respiratory depression, including bradypnea, is the hallmark sign of opioid toxicity. Morphine suppresses the brainstem’s respiratory centers, reducing respiratory rate and depth, which can become life-threatening without intervention.
D. Hyperactive deep tendon reflexes: Opioids tend to cause central nervous system depression, which would more likely lead to diminished reflexes. Hyperactive reflexes are not associated with morphine toxicity and may suggest a different neurological issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Calculation:
Total volume = 100 mL.
- Convert the infusion time from minutes to hours.
Infusion time = 30 min / 60 min/hr
= 0.5 hr.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Auditory hallucinations: The client reports hearing voices telling them to act (“I'm being told that it's better to end myself...”), which is a clear example of auditory hallucinations. These are a core positive symptom of schizophrenia and often command in nature.
- Echolalia: The client repeating the nurse’s words indicates echolalia, which reflects disorganized thought and speech. It is another classic positive symptom of schizophrenia and demonstrates impaired cognitive filtering.
Rationale for Incorrect Choices:
- Magical thinking: Magical thinking involves believing one’s thoughts can cause events in the physical world, such as thinking they can control others with their mind. This is not evident in the client’s current statements.
- Thought deletion: Thought deletion is the belief that external forces are removing thoughts from one’s mind. The client does not express this; instead, they report added stimuli (voices), not missing thoughts.
- Boundary impairment: Boundary impairment involves difficulty recognizing personal space or ownership, such as using others’ belongings inappropriately. This behavior has not been described in the current assessment.
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