A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
Prolonged wound healing
Nausea
Stevens-Johnson syndrome
Renal failure
The Correct Answer is B
Rationale:
A. This is not a common adverse effect associated with morphine.
B. Nausea is a common adverse effect of morphine and should be monitored for, particularly in pediatric patients.
C. Stevens-Johnson syndrome is a severe allergic reaction and is not typically associated with morphine.
D. While morphine can cause urinary retention, it is not typically associated with renal failure.
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Related Questions
Correct Answer is ["A","B","C","F","H"]
Explanation
Rationale:
A.Clients with sickle cell disease are at increased risk for infections, including those caused by pneumococcus. Ensuring vaccination status helps prevent future complications.
B. Folic acid supplementation may be part of the overall management of sickle cell disease, but it is not a priority intervention during a vaso-occlusive crisis.
C. Vaso-occlusive crises can lead to tissue hypoxia due to impaired blood flow.
Continuous monitoring of oxygen saturation helps in assessing tissue perfusion and detecting hypoxemia early.
D. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.
E.Cold can cause vasoconstriction, worsening the pain and sickling process. Warm compresses are more appropriate for promoting comfort and improving circulation.
F. Meperidine (Demerol) is a potent opioid analgesic that can help alleviate severe pain associated with vaso-occlusive crises.
G. The nurse should not restrict oral intake, as hydration is important to prevent dehydration and further sickling.
H. Hydroxyurea is used to prevent vaso-occlusive crises in patients with sickle cell disease but is not typically administered during an acute crisis. This is a medication that reduces the frequency and severity of vaso-occlusive crises by increasing the production of fetal hemoglobin, which prevents sickling.
Correct Answer is B
Explanation
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
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