A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?
The client's blood pressure has been reduced.
The client exhibits diaphoresis
The client is not grimacing
The client has an elevated heart rate
The Correct Answer is C
Answer: (C) The client is not grimacing
Rationale:
A) The client's blood pressure has been reduced:
While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.
B) The client exhibits diaphoresis:
Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.
C) The client is not grimacing:
The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.
D) The client has an elevated heart rate:
An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.
The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.
Correct Answer is B
Explanation
b. Methylergonovine.
Explanation:
Postpartum hemorrhage is a significant complication that can occur after childbirth. Methylergonovine is a medication commonly used to manage postpartum hemorrhage. It is an ergot alkaloid that helps to contract the uterus, reducing bleeding. It is typically administered either intramuscularly or orally.
Option a, Terbutaline, is a medication used for the management of preterm labor by relaxing the uterine smooth muscles. It is not indicated for postpartum hemorrhage.
Option c, Magnesium sulfate, is a medication used for the prevention and treatment of seizures in patients with preeclampsia or eclampsia. It is not specifically indicated for postpartum hemorrhage.
Option d, Nifedipine, is a calcium channel blocker commonly used to manage hypertension. It is not indicated for postpartum hemorrhage.
It's important to note that the specific management of postpartum hemorrhage may vary depending on the underlying cause, severity of bleeding, and individual patient factors. The healthcare provider will determine the most appropriate interventions and medications for each case.
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