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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Dehydration is not directly associated with gastroesophageal reflux, which involves gastric acid backflow. Dehydration affects fluid balance, not reflux mechanisms, so this statement is inaccurate and irrelevant to preterm contractions, making it incorrect.
Choice B reason: Dehydration is not caused by decreased hemoglobin and hematocrit; rather, it may elevate these due to hemoconcentration. This statement reverses the relationship, making it factually incorrect and unrelated to preterm labor risks.
Choice C reason: Dehydration can increase preterm labor risk by reducing uterine blood flow and triggering contractions via oxytocin release. This evidence-based link supports hydration as a preventive measure, making it the correct statement for teaching in this scenario.
Choice D reason: Dehydration is treated with fluid replacement, not calcium supplements, which address bone health or specific deficiencies. This treatment is irrelevant to dehydration or preterm labor, making it an incorrect and inappropriate recommendation.
Correct Answer is D
Explanation
Choice A reason: Assuring the client about future pregnancies dismisses her current emotional loss, potentially invalidating grief. Stillbirth triggers complex hormonal and psychological responses, including postpartum depression risk. This approach fails to address immediate emotional needs, hindering the grieving process and emotional recovery in perinatal loss.
Choice B reason: Avoiding discussion of the newborn ignores the client’s need to process her loss. Acknowledging the baby’s existence is critical for healthy mourning, as psychological research shows verbalizing grief aids emotional integration. Silence may suppress coping, prolonging unresolved grief and complicating psychological adjustment post-stillbirth.
Choice C reason: Discouraging friends from seeing the newborn dismisses the client’s need for social support. Communal acknowledgment of loss mitigates isolation, a key factor in grief recovery. This action disrupts psychological coping by limiting social validation, potentially exacerbating feelings of loneliness and hindering emotional healing after stillbirth.
Choice D reason: Offering to take pictures acknowledges the baby’s significance, aiding the client’s grieving process. Photographs serve as tangible memories, supported by psychological research as therapeutic in perinatal loss. This intervention fosters emotional closure, validates the loss, and supports healthy mourning, aligning with compassionate care principles.
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