A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Sleepy, but arousing when her name is called.

Respiratory rate 8/min.

Pain level of 6 on a scale from 0 to 10.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Being sleepy but arousing when her name is called is a common side effect of morphine, which is a potent opioid analgesic. Morphine can cause drowsiness and sedation, but this is not necessarily an adverse effect unless it progresses to a state where the patient cannot be easily aroused. Therefore, while this is a side effect, it is not as concerning as respiratory depression.

Choice B reason:

A respiratory rate of 8/min is an adverse effect of morphine. Opioids like morphine can depress the respiratory center in the brain, leading to a decreased respiratory rate. Normal respiratory rates for adults are typically between 12 and 20 breaths per minute. A rate of 8 breaths per minute indicates significant respiratory depression, which can be life-threatening and requires immediate intervention.

Choice C reason:

A pain level of 6 on a scale from 0 to 10 indicates that the morphine has not fully alleviated the client’s pain. While this is important to address, it is not an adverse effect of the medication. The primary concern with morphine administration is monitoring for serious side effects like respiratory depression.

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Correct Answer is A

Explanation

Choice A reason:

Reducing the intake of vitamin K-rich foods is not recommended for preventing osteoporosis. Vitamin K plays a crucial role in bone health by helping to regulate calcium in the bones and blood. It is essential for the formation of osteocalcin, a protein that binds calcium to the bone matrix, thereby strengthening bones1. Therefore, reducing vitamin K intake could negatively impact bone health.

Choice B reason:

Reducing sodium intake is beneficial for preventing osteoporosis. High sodium intake can lead to increased calcium excretion in the urine, which can weaken bones over time2. Lowering sodium intake helps to retain calcium in the body, promoting better bone health.

Choice C reason:

Decreasing caffeine intake is advisable for preventing osteoporosis. Excessive caffeine consumption can interfere with calcium absorption and increase calcium excretion, which can weaken bones. Limiting caffeine intake helps to ensure that more calcium is available for bone maintenance and strength.

Choice D reason:

Limiting the intake of soft drinks is also recommended for preventing osteoporosis. Many soft drinks contain phosphoric acid, which can lead to an imbalance in calcium and phosphorus levels in the body, potentially weakening bones. Reducing soft drink consumption helps to maintain a healthier balance of these minerals, supporting bone health.

A. Babinski’s sign B. Chvostek’s sign C. Brudzinski’s sign D. Kernig’s sign

Correct Answer is B

Explanation

Choice A reason: Babinski’s sign

Babinski’s sign is a reflex action where the big toe moves upward or toward the top surface of the foot and the other toes fan out when the sole of the foot is stimulated. This sign is used to assess neurological function, particularly in the context of central nervous system disorders. It is not related to hypocalcemia, which is the likely cause of the tingling sensation in this scenario.

Choice B reason: Chvostek’s sign

Chvostek’s sign is a clinical indicator of hypocalcemia. It is elicited by tapping the facial nerve at the angle of the jaw, which causes twitching of the facial muscles. Hypocalcemia is a common complication following thyroidectomy due to potential damage or removal of the parathyroid glands, which regulate calcium levels. The tingling sensation reported by the client is a classic symptom of hypocalcemia, making Chvostek’s sign the most relevant assessment.

Choice C reason: Brudzinski’s sign

Brudzinski’s sign is used to assess for meningitis. It involves flexing the client’s neck and observing for involuntary flexion of the hips and knees. This sign is not related to hypocalcemia or the symptoms described by the client following thyroidectomy.

Choice D reason: Kernig’s sign

Kernig’s sign is another test for meningitis. It involves flexing the client’s hip and knee, then straightening the knee. Pain and resistance to straightening the knee indicate a positive Kernig’s sign. This sign is not relevant to the assessment of hypocalcemia or the symptoms described by the client.

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A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

Correct Answer is B

Explanation

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