Patient Data

Exhibits

The nurse addresses the client's pain and plans interventions to reduce further complications.

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

The nurse monitors the client's
dropdown
after administering the morphine. The nurse should include
dropdown
to reduce complications of the client's injury.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for correct choices:

• Respirations: Morphine is an opioid analgesic that can depress the respiratory center in the brainstem, leading to slowed breathing and hypoventilation. Monitoring respirations after administration is critical to detect early signs of opioid-induced respiratory depression.

• Ice application to the shoulder: Applying ice reduces swelling, pain, and inflammation by causing vasoconstriction and limiting fluid accumulation at the injury site. For an acute humeral fracture with significant swelling and bruising, cold therapy is the appropriate intervention.

Rationale for incorrect choices:

• Nausea: While morphine can cause nausea and vomiting as side effects, they are not the most life-threatening concerns compared to respiratory depression. Monitoring nausea is appropriate but not the priority when evaluating opioid safety.

• Blood pressure: Morphine can cause hypotension, but this effect is less common and typically secondary to respiratory depression and vasodilation. Continuous monitoring of blood pressure is helpful, but respiratory monitoring takes priority in detecting opioid complications.

• Early active range of motion: Active movement of the injured arm is not recommended immediately after a displaced humeral fracture, as it can worsen displacement and interfere with healing. Immobilization and stabilization are required before introducing range-of-motion exercises.

• Heat application to the shoulder: Heat increases blood flow to tissues, which can worsen swelling and bleeding in the acute phase of injury. Applying heat too soon after a fracture increases the risk of complications rather than reducing them.

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Correct Answer is C

Explanation

A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.

B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.

C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.

D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.

A. Argumentativeness and use of profanity. B. Periodic sighing and shaking the head. C. Decreased activity level and change in affect. D. Repeated requests for attention from the nurse.

Correct Answer is A

Explanation

A. Argumentativeness and use of profanity: These behaviors may indicate escalating agitation and a risk for violence. Monitoring for verbal aggression is essential because it can quickly progress to physical aggression, making safety the priority concern.

B. Periodic sighing and shaking the head: These are signs of frustration or discouragement but are less concerning than overt verbal aggression. They do not immediately signal a risk of harm to others.

C. Decreased activity level and change in affect: A decline in activity or affect may suggest depression or withdrawal but does not indicate an acute risk of violent escalation like pacing and scowling combined with verbal aggression.

D. Repeated requests for attention from the nurse: Frequent requests may reflect anxiety or dependency but do not typically indicate imminent aggression. While they should be addressed, they are not the most critical behaviors to monitor in this scenario.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse needs to determine the priority assessment before administering morphine. Select from Word Choices to complete the sentence. Before administering morphine, the most important assessment to perform is to check the client's ______________

Correct Answer is C

Explanation

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is A

Explanation

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