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 A
Explanation
The nurse should include the instruction to "verify the identity of anyone who wants to remove your baby from the room" in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.
Option b is incorrect because it may not be safe for the parent to leave their baby unattended in their room while they walk in the hallway.
Option c is incorrect because newborns typically have two identification bands, one on their arm and one on their leg.
Option d is incorrect because parents should not leave the unit with their baby without proper authorization and discharge procedures.
Correct Answer is B
Explanation
Applying heat to the affected joints can help relieve pain and stiffness ¹. A heating pad or warm compress
can be used to apply heat to the hands.
The other options are not correct because:
a) Sleeping on a soft mattress is not mentioned as a way to manage osteoarthritis symptoms.
b) spirin should be taken with food or milk to reduce stomach irritation .
c) Exercising inflamed joints excessively can worsen symptoms. It is important to balance rest and activity.
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