Try Naxlex NCLEX-RN (Free-Trial)

The nurse is evaluating the client’s response to pain management.

Exhibits

Click to highlight the findings that indicate the client is experiencing the therapeutic effects of the medication.

Pain level presently 3 on a 0 to 10 scale. The client reports feeling "sleepy." Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer. New mild cough noted. Repositions in bed with minimal assistance. Attempted to get up to the chair, but experienced dizziness with standing.

Pain level presently 3 on a 0 to 10 scale

The client reports feeling "sleepy."

Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer.

New mild cough noted.

Repositions in bed with minimal assistance.

Attempted to get up to the chair, but experienced dizziness with standing.

Answer and Explanation

The Correct Answer is ["A","C","E"]

Rationale for correct choices:

• Pain level presently 3 on a 0 to 10 scale: A reduction in pain from 8/10 to 3/10 indicates that the morphine is effectively alleviating the client’s pain. Effective analgesia allows for improved comfort, participation in breathing exercises, and reduced stress response.

• Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer: Increased inspiratory volume demonstrates improved lung expansion, indicating that pain control is facilitating better respiratory effort. This is especially important to prevent atelectasis and maintain adequate oxygenation after rib fractures.

• Repositions in bed with minimal assistance: Ability to move with less assistance reflects improved comfort and mobility due to effective pain management. This shows the therapeutic effect of analgesia in enabling functional activity without excessive pain.

Rationale for incorrect choices:

• Client reports feeling "sleepy": Sleepiness is a common side effect of morphine, reflecting central nervous system depression rather than a therapeutic effect of pain relief. While mild sedation can accompany effective analgesia, it does not directly indicate improvement in the underlying condition.

• New mild cough noted: The appearance of a new cough is not a direct indicator of therapeutic pain relief. It may reflect airway irritation, increased secretions, or a response to deeper breathing, but it is not a measure of analgesic effectiveness.

• Attempted to get up to the chair, but experienced dizziness with standing: Dizziness indicates a side effect of the opioid (orthostatic hypotension or sedation), not a therapeutic response. This finding requires monitoring and safety interventions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Temperature B. Heart rate C. Respiratory rate D. Blood pressure

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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

Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

A client with Parkinson's disease receives a prescription for benztropine. Which common adverse effect(s) should the nurse include in the teaching plan? Select all that apply