A nurse is caring for a client

Exhibits

A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale:
A. Morphine typically causes miosis (constricted pupils), not dilation. A pupil diameter of 6 mm (dilated pupils) is not an expected therapeutic effect, but it is not the most immediately life-threatening finding in this scenario compared with severe hypotension.

B. This equates to about 30 mL/hr, which is borderline low but still may be acceptable depending on the client’s weight, hydration status, and clinical context. Morphine can also cause urinary retention, so this finding should be monitored but is not the priority.

C. Constipation is a very common adverse effect of morphine due to decreased gastrointestinal motility. While important to address with stool softeners or laxatives, it is not an acute emergency.

D. This is the priority finding because it indicates severe hypotension, which can lead to decreased tissue perfusion, shock, and organ failure. Morphine can cause vasodilation and histamine release, contributing to hypotension, especially when given IV. This requires immediate intervention and provider notification first, as it is life-threatening.

Rationale for correct choices:

• Preeclampsia: The client demonstrates classic and worsening findings of preeclampsia with severe features, including hypertension, proteinuria, thrombocytopenia, elevated liver enzymes, RUQ pain, and hyperreflexia. These findings indicate endothelial damage and multi-organ involvement, placing the client at highest risk for complications such as eclampsia and HELLP syndrome.
• Urinalysis: The presence of proteinuria (25 mg/dL) is a key diagnostic criterion for preeclampsia. It reflects renal involvement and glomerular damage, making it a critical indicator supporting the diagnosis.
• Pain assessment: The client’s right upper quadrant (RUQ) pain is highly significant. This type of pain indicates hepatic involvement (liver swelling or ischemia) and is a warning sign of severe preeclampsia or progression to HELLP syndrome. It is a critical clinical finding that correlates with worsening disease severity.

Rationale for incorrect choices:

• Preterm labor: No contractions, cervical changes, or uterine activity are present.
• Chorioamnionitis: No fever, uterine tenderness, or infection signs; WBC is within expected range for pregnancy.
• Serum WBC count: Slight elevation is normal in pregnancy and not specific for preeclampsia.
• Fundal assessment: Fundal height is appropriate (29 cm at 30 weeks) and not indicative of complications.
• Fetal monitor results: Fetal heart rate is normal (140/min), so no evidence of fetal distress.
• Hemoglobin: Within normal limits and not indicative of the condition.