A nurse is preparing to administer an opioid agonist to a client who has acute pain. For which of the following manifestations should the nurse monitor as an adverse effect of this medication?

Irritating cough

Tachypnea

Hypertension

Urinary retention

Answer and Explanation

The Correct Answer is D

A. Irritating cough. Opioid agonists do not typically cause an irritating cough. In fact, opioids like codeine are used as antitussives to suppress cough reflexes.
B. Tachypnea. Opioids depress the central nervous system, leading to respiratory depression rather than an increased respiratory rate (tachypnea). The nurse should monitor for bradypnea instead.
C. Hypertension. Opioids commonly cause hypotension due to vasodilation and central nervous system depression. Hypertension is not a typical adverse effect.
D. Urinary retention. Opioids can increase sphincter tone and suppress the urge to void, leading to urinary retention. This is a known side effect and should be monitored, especially in older adults or those with underlying bladder issues.

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Correct Answer is A

Explanation

A. Wait 30 minutes and take an oral temperature. Waiting 30 minutes ensures an accurate reading, as consuming hot or cold foods or drinks can alter oral temperature results.
B. Advise the patient to drink a glass of cold water. Drinking cold water could artificially lower the oral temperature, leading to an inaccurate measurement.
C. Take a rectal temperature. A rectal temperature is not necessary in this situation unless a core temperature is required for clinical reasons.
D. Take the oral temperature as planned. Taking the oral temperature immediately after hot soup can result in a falsely elevated reading, making it unreliable.

A. Due to a specific stimulus B. Caused by a single physiological situation C. Universally the same for everyone D. Subjective

Correct Answer is D

Explanation

A. Due to a specific stimulus. Pain can occur with or without an identifiable stimulus. Conditions like neuropathic pain or phantom limb pain exist without an obvious external cause.
B. Caused by a single physiological situation. Pain can result from multiple factors, including tissue damage, nerve dysfunction, inflammation, and psychological influences. It is not limited to one specific physiological cause.
C. Universally the same for everyone. Pain perception varies widely between individuals due to differences in pain tolerance, cultural background, past experiences, and psychological state.
D. Subjective. Pain is defined as whatever the patient says it is, making it a subjective experience. It cannot be measured objectively, and the best indicator of pain is the patient’s self-report.

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A nurse is preparing to administer an opioid agonist to a client who has acute pain. For which of the following manifestations should the nurse monitor as an adverse effect of this medication?

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