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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The therapeutic relationship can be described in terms of four sequential phases: preinteraction phase, introduction/orientation phase, working phase, and termination phase . In the working phase, most of the therapeutic interventional activities are carried out . This is the phase where the nurse should help the client develop problem-solving skills.
The other options are not correct because:
a) The preinteraction phase starts when the nurse is given the responsibility to start a therapeutic relationship with a patient.
c) The introduction/orientation phase is the first meeting of the nurse with her client (patient).
d) The termination phase is the final stage of the nurse-client relationship.
Correct Answer is D
Explanation
d. Apply the dressing loosely over the incision.
Explanation:
The correct answer is d. Apply the dressing loosely over the incision.
When caring for an older adult client, it is important for the nurse to be sensitive to age-related changes and promote their comfort and well-being. Applying the dressing loosely over the incision allows for beter circulation and ventilation, which can help prevent complications such as skin breakdown and infection.
Option a is not the correct answer. Asking the client to help with the dressing change may not be appropriate, as postoperative clients, especially older adults, may have limited mobility or dexterity. It is the nurse's responsibility to provide the necessary care and support during the dressing change.
Option b is not the correct answer. Waiting for the client to approach the nurse for assistance may lead to delays in care and could potentially compromise the client's healing process. The nurse should proactively assess the client's needs and provide appropriate care.
Option c is not the correct answer. Using paper tape for securing the new dressing does not specifically address sensitivity to age-related changes. While paper tape may be gentle on the skin, it is not the primary consideration in this situation.
By applying the dressing loosely over the incision, the nurse demonstrates sensitivity to age-related changes and promotes the client's comfort and optimal healing. This approach takes into account the potential for decreased skin elasticity and fragility in older adults, allowing for proper circulation and reducing the risk of complications.
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