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 {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}
Explanation
Rationale:
- Platelet count: A low platelet count (<100,000/mm³) is a hallmark of HELLP syndrome but can also appear in severe preeclampsia. Therefore, thrombocytopenia supports both diagnoses.
- Alanine aminotransferase (ALT): Elevated ALT indicates hepatic involvement due to hepatocellular injury, which is a defining feature of HELLP syndrome but not required for preeclampsia diagnosis.
- Blood pressure: Severe hypertension (≥160/110 mm Hg), as seen in this client, is diagnostic of severe preeclampsia. It may also be present in HELLP syndrome due to overlapping pathophysiology.
- Hemoglobin: Low hemoglobin can reflect hemolysis, which is part of the HELLP acronym (Hemolysis, Elevated Liver enzymes, Low Platelets). Preeclampsia does not typically present with anemia unless HELLP develops.
Correct Answer is C
Explanation
Rationale:
A. A small area rug is placed at the front door: Area rugs increase the risk of falls, especially in older adults or clients with mobility issues. Rugs should be removed or secured with non-slip backing to prevent tripping hazards at entrances and high-traffic areas.
B. The water heater is set at 54° C (129.2° F): This temperature is too high and poses a significant risk for burns or scalding. The recommended maximum water heater setting for safety is 49° C (120° F), especially in homes with children or older adults.
C. The batteries in the smoke alarms are changed annually: Changing smoke alarm batteries once a year aligns with fire safety recommendations. Functioning smoke alarms are a critical part of home safety and fire prevention.
D. A single light fixture hangs along the sidewalk to the house: One light may not provide adequate visibility, especially in poor weather or at night. Multiple, evenly spaced light sources are more effective for preventing trips or falls along walkways.
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