A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

Hyperactive deep tendon reflexes

Fluid retention

Prolonged QT interval

Bradypnea

Answer and Explanation

The Correct Answer is D

Choice A reason: Hyperactive deep tendon reflexes are not linked to morphine toxicity. Morphine, an opioid, depresses the central nervous system, reducing reflexes. Hyperactive reflexes suggest neurological or stimulant effects, not opioid overdose, which primarily causes respiratory and consciousness depression in affected clients.
Choice B reason: Fluid retention is not a primary sign of morphine toxicity. Morphine may cause urinary retention via sphincter tone increase, but fluid overload is unrelated. Toxicity manifests as respiratory depression or sedation, driven by mu-opioid receptor overstimulation, not fluid balance alterations.
Choice C reason: Prolonged QT interval is associated with medications like antiarrhythmics, not morphine. Morphine toxicity primarily causes respiratory depression and sedation via central nervous system effects. Cardiac effects are rare, and QT prolongation is not a hallmark of opioid overdose in clinical settings.
Choice D reason: Bradypnea indicates morphine toxicity, as opioids depress the brainstem’s respiratory center via mu-receptor overstimulation. This slows breathing, risking hypoxia and respiratory arrest, a life-threatening complication requiring immediate intervention like naloxone to reverse opioid effects and restore normal respiratory function.

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Correct Answer is C

Explanation

Choice A reason: Disulfiram is an oral medication, not injectable, used to deter alcohol consumption by causing adverse reactions. Monthly injections apply to drugs like naltrexone, not disulfiram, which requires daily oral dosing to maintain its deterrent effect in alcohol use disorder treatment.
Choice B reason: Taking disulfiram before quitting alcohol is incorrect, as it is started post-abstinence to prevent relapse. Disulfiram inhibits aldehyde dehydrogenase, causing acetaldehyde buildup if alcohol is consumed, making it effective only in alcohol-free clients to deter drinking.
Choice C reason: Avoiding over-the-counter medications with alcohol is correct, as disulfiram causes severe reactions (nausea, flushing) with alcohol ingestion, including from medications like cough syrups. This reflects understanding of disulfiram’s mechanism, ensuring safety by preventing unintended alcohol exposure.
Choice D reason: Continuing disulfiram for 5 years is not standard, as duration varies per treatment plan. Disulfiram supports early abstinence, not fixed long-term use. This statement misrepresents its role, as therapy length depends on individual recovery needs, not a predetermined timeframe.

A. Body mass index of 32 B. Temperature 36.8°C (98°F) C. White blood cell count 8,000/mm³ D. Blood glucose 90 mg/dL

Correct Answer is A

Explanation

Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.

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A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

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