A nurse is assessing a client who received morphine for severe pain 30 minutes ago. Which of the following findings is the nurse’s priority?

Last bowel movement was 3 days ago

Respiratory rate 7/min

Reports pain of 8 on a scale from 0 to 10

Distended bladder

Answer and Explanation

The Correct Answer is B

Choice A Reason:

While it is important to monitor bowel movements, especially since opioids like morphine can cause constipation, this is not the immediate priority. Opioid-induced constipation is a common side effect due to decreased gastrointestinal motility. However, it does not pose an immediate life-threatening risk compared to respiratory depression.

Choice B Reason:

A respiratory rate of 7 breaths per minute is significantly below the normal range for adults, which is typically 12-20 breaths per minute. This indicates severe respiratory depression, a known and potentially fatal side effect of morphine. Immediate intervention is required to ensure the patient’s airway is maintained and to prevent respiratory arrest.

Choice C Reason:

Although the client reporting a pain level of 8 out of 10 indicates that the pain is not adequately controlled, this is not the most urgent concern compared to respiratory depression. Pain management is crucial, but ensuring the patient’s respiratory function takes precedence.

Choice D Reason:

A distended bladder can be a side effect of morphine due to urinary retention. While this needs to be addressed to prevent discomfort and potential complications, it is not as critical as managing a severely low respiratory rate.

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Correct Answer is B

Explanation

Choice A Reason

Bending at the waist to pick up the box is not recommended as it can put excessive strain on the lower back. Proper lifting techniques involve bending at the knees and hips, not the waist, to use the stronger muscles of the legs and reduce the risk of back injury. This method helps maintain the natural curve of the spine and distributes the load more evenly.

Choice B Reason

When lifting the box, keeping it close to the body is the most appropriate action. This technique reduces the lever arm distance, thereby decreasing the strain on the back muscles and spine. Holding the load close to the body ensures better control and stability, making it easier to lift and carry the box safely.

Choice C Reason

Keeping the feet close together when lifting a box is not advisable. A wide stance, with feet shoulder-width apart, provides better balance and stability. This position allows for a more secure lift and reduces the risk of losing balance or straining muscles during the lifting process.

Choice D Reason

Relaxing the abdominal muscles to prevent straining the back is incorrect. Engaging the core muscles, including the abdominals, provides additional support to the spine and helps maintain proper posture during lifting. Tightening the abdominal muscles can help stabilize the torso and reduce the risk of back injury.

A. The client has a symmetrical smile. B. The client’s tongue is in a midline position. C. The client turns their head against resistance. D. The client’s pupils constrict in response to light.

Correct Answer is A

Explanation

Choice A Reason:

Cranial nerve VII, also known as the facial nerve, is responsible for controlling the muscles of facial expression. When assessing this nerve, a nurse would expect to see symmetrical facial movements, such as a symmetrical smile. This indicates that the facial nerve is functioning properly on both sides of the face. Any asymmetry could suggest a problem with the facial nerve, such as Bell’s palsy or a stroke.

Choice B Reason:

The position of the tongue is controlled by cranial nerve XII, the hypoglossal nerve, not cranial nerve VII. The hypoglossal nerve is responsible for the movements of the tongue, and a midline position indicates normal function of this nerve. Therefore, this response is not relevant to the assessment of cranial nerve VII.

Choice C Reason:

Turning the head against resistance is a test for cranial nerve XI, the accessory nerve. This nerve controls the sternocleidomastoid and trapezius muscles, which are involved in head and shoulder movements. Assessing the ability to turn the head against resistance helps evaluate the function of the accessory nerve, not the facial nerve.

Choice D Reason:

Pupillary constriction in response to light is a function of cranial nerve III, the oculomotor nerve. This nerve controls the muscles that constrict the pupil in response to light, a reflex known as the pupillary light reflex. This response is not related to the function of cranial nerve VII.

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A nurse is assessing a client who received morphine for severe pain 30 minutes ago. Which of the following findings is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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