A patient with metastatic cancer who was taking hydromorphone orally at home is now receiving the medication intravenously while in the hospital.
To evaluate if the patient is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?
Respiratory rate.
Pain scale.
Blood pressure.
Level of consciousness.
The Correct Answer is B
Choice A rationale
While monitoring the respiratory rate is important in a patient receiving opioids like hydromorphone, it does not directly indicate whether the patient is receiving an equianalgesic dose of the medication.
Choice B rationale
Pain scale assessment is the most direct way to evaluate if the patient is receiving an equianalgesic dose of hydromorphone. Equianalgesic refers to a dose of one opioid that would provide the same level of pain relief as a given dose of another opioid. If the patient’s pain is well-controlled, it suggests that the dose of hydromorphone is equianalgesic to the dose of the previous opioid.
Choice C rationale
Monitoring blood pressure is important in a patient receiving opioids as these medications can cause hypotension. However, blood pressure does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.
Choice D rationale
While it’s important to monitor the level of consciousness in a patient receiving opioids as these medications can cause sedation, it does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
Choice A rationale
The patient is resting and cooperative, which indicates a calm and alert state, not agitation. Orientation x means the patient is aware of person, place, time, and situation, which is a normal finding. Dizziness is not mentioned in the patient’s condition. Pupils being equal and reactive to light is a normal finding and does not indicate a neurological issue.
Choice B rationale
Bradycardia refers to a slower than normal heart rate, which is not mentioned in the patient’s condition. Weak bilateral radial pulses could indicate poor blood circulation, but this is not mentioned in the patient’s condition. Capillary refill of 2 seconds is a normal finding. The absence of lower leg edema is a normal finding and does not indicate a cardiovascular issue.
Choice C rationale
Clear breath sounds are a normal finding and indicate that the patient’s lungs are free of obstructions or fluid.
Choice D rationale
The last reported bowel movement being 4 days ago could indicate constipation, but this is not mentioned in the patient’s condition.
Correct Answer is B
Explanation
Choice A rationale
Phobia is characterized by an excessive and irrational fear response. In this case, the patient’s symptoms do not indicate a specific fear, but rather general distress and intrusive thoughts related to a traumatic event.
Choice B rationale
The patient’s symptoms, which include distressing thoughts and memories of the house collapsing, difficulty sleeping, and a significant change in mood, are indicative of acute stress disorder related to traumatic stress exposure. Acute stress disorder can occur within a month of experiencing a traumatic event, like a natural disaster.
Choice C rationale
Hallucinations involve perceiving something that is not present. The patient’s symptoms do not include any indications of hallucinations.
Choice D rationale
Separation anxiety involves excessive fear or anxiety about separation from those to whom the individual is attached. The patient’s symptoms do not indicate a fear of separation, but rather distress related to a traumatic event.
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