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.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Compare a list of common medications to treat a condition to the actual prescriptions: This approach does not meet the definition of medication reconciliation, which focuses on comparing the client’s actual prior medications to new orders to prevent errors.
B. Compare the prescription to the allergy history of the client: While this is an important safety check, it is not the primary purpose of medication reconciliation. Allergy review is a separate step done for every prescribed medication, not specifically during reconciliation.
C. Compare the medication label to the provider's prescription on three occasions before administration: This is part of the "three checks" of medication administration to ensure accuracy and safety, but it is unrelated to the reconciliation process that occurs during admission, transfer, or discharge.
D. Compare the client's list of home medications to the admission prescriptions written for the client: This is the central process in medication reconciliation. It ensures continuity of care, prevents omissions, duplications, or interactions, and identifies changes that need clarification.
Correct Answer is C
Explanation
Rationale:
A. The client experiences self-doubt when making decisions: Indecisiveness and self-doubt are common symptoms of major depressive disorder and do not reflect improvement. They typically indicate ongoing low self-esteem and cognitive impairment.
B. The client exhibits a flat affect: A flat or blunted affect is a hallmark of depressive states. Persistence of this symptom suggests the depression is still significantly impacting the client’s emotional expression.
C. The client can express angry feelings: Being able to express emotions such as anger can indicate emotional engagement and increased energy, which are signs of clinical improvement in depression.
D. The client looks down when speaking to others: This behavior suggests ongoing feelings of worthlessness or poor self-confidence, commonly seen in depressive states and not indicative of recovery.
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