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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

Answer and Explanation

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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Correct Answer is B

Explanation

b. Rationalization

Explanation:

The correct answer is b. Rationalization.

Rationalization is a defense mechanism characterized by the individual's atempt to justify or explain their behavior or actions in a way that makes it more acceptable to themselves or others. It involves providing logical-sounding reasons or excuses to mask or minimize the real underlying reasons for their behavior.

In this scenario, the client is atributing their recent behavior to the loss of their job, using it as a justification or explanation for their actions. By blaming the job loss, they are rationalizing their behavior as a direct result of the circumstances they faced.

Option a, Projection, involves atributing one's own unacceptable thoughts, feelings, or behaviors to others.

This defense mechanism does not apply to the client's statement about their job loss.

Option c, Repression, involves the unconscious blocking of unwanted thoughts or feelings. It does not relate to the client's behavior or their explanation for it.

Option d, Sublimation, is a defense mechanism where an individual channels or redirects unacceptable impulses or emotions into socially acceptable behaviors or activities. It is not applicable in this context since the client is not expressing their emotions or impulses through alternative constructive means.

By identifying the client's explanation as rationalization, the nurse recognizes the defense mechanism being used and gains insight into how the client is coping with their emotions and justifying their behavior in response to the job loss. This understanding can guide the nurse in providing appropriate support and interventions to help the client manage their anger more eﬀectively.

A. Serve meals with plastic utensils. B. Assign another client to accompany the client to therapy sessions C. Assign the client to a private room D. Check on the client every 4 hr

Correct Answer is A

Explanation

Answer: A

Rationale:

A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.

B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.

C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.

D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is participating in a therapy session for anger management. The client states that their recent behavior is due to the loss of their job. The nurse should identify that the client is using which of the following defense mechanisms?

Correct Answer is B

Explanation

A nurse is caring for a client who atempted suicide. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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