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Patient Data

The charge nurse places a fall precautions sign on the client's door. Which side effects of morphine could contribute to this client's fall risk? Select all that apply

Nausea

Euphoria

Itching

Orthostatic hypotension

Seizures

Urinary retention

Sedation

Answer and Explanation

Correct Answer : A,D,G

A. Nausea: Morphine commonly causes nausea, which can lead to dizziness and unsteadiness when standing or moving. This increases the client’s risk of falls, especially when transitioning from bed to chair or ambulating postoperatively.

B. Euphoria: While morphine may cause a sensation of euphoria, this emotional effect alone does not directly contribute to physical instability or fall risk in the immediate postoperative period.

C. Itching: Itching is a common side effect of opioids but does not impair balance or mobility directly, so it is not a significant contributor to fall risk.

D. Orthostatic hypotension: Morphine can cause vasodilation, leading to drops in blood pressure when moving from lying to sitting or standing. Orthostatic hypotension can result in lightheadedness or fainting, sharply increasing the risk of falls.

E. Seizures: Seizures are rare side effects of morphine, typically associated with very high doses or toxicity. They are not in standard therapeutic use to be considered a primary fall risk factor.

F. Urinary retention: Urinary retention is a side effect of morphine but does not directly cause instability or contribute to falls unless it leads to urgency and hurried movement, which is less typical.

G. Sedation: Sedation is one of the most significant opioid side effects contributing to falls. Reduced alertness and slower reflexes make it much harder for clients to safely ambulate or protect themselves from falls.

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Correct Answer is ["A","B","C"]

Explanation

Trembling: Trembling is a known side effect of albuterol due to its beta-2 adrenergic stimulation. Albuterol can cause fine muscle tremors, particularly in the hands, as part of its systemic sympathomimetic effects following inhalation.
Headache: Headache can result from vasodilation and mild CNS stimulation caused by beta-agonists like albuterol. It is a frequently reported side effect and can occur even with appropriate dosing, particularly in sensitive individuals.
Heart rate 129 beats/minute: Tachycardia is a common adverse effect of albuterol because it stimulates beta-1 receptors at higher doses, leading to an increased heart rate. A heart rate of 129 beats/minute post-treatment indicates a significant sympathetic response.
Respirations 20 breaths/minute: A decrease in respiratory rate from 36 to 20 breaths/minute reflects clinical improvement in respiratory distress. It is a positive response to albuterol therapy, not an adverse reaction.
Oxygen saturation 99% on room air: Improvement of oxygen saturation from 83% to 99% is a therapeutic goal with bronchodilator use. This indicates better gas exchange after albuterol treatment and is not an adverse reaction.

A. Feverfew may interact with aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew. C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew. D. Increased anxiety and nervousness have been reported by those taking feverfew.

Correct Answer is A

Explanation

A. Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs): Feverfew has antiplatelet effects that can increase the risk of bleeding when combined with aspirin or NSAIDs. Teaching the client about this interaction is critical to prevent serious adverse effects such as gastrointestinal bleeding or easy bruising.

B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew: Although this is important information for clients with specific allergies, it is not as immediately critical as informing about drug interactions that can cause dangerous bleeding risks.

C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew: These gastrointestinal side effects are common but generally mild and not life-threatening, making them less critical to address compared to drug interactions.

D. Increased anxiety and nervousness have been reported by those taking feverfew: While some clients may experience mild mood changes, this is less common and not as serious as the bleeding risks associated with concurrent use of feverfew and other antiplatelet agents.

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Patient Data The charge nurse places a fall precautions sign on the client's door. Which side effects of morphine could contribute to this client's fall risk? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?

Correct Answer is A

Explanation

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Patient Data

The charge nurse places a fall precautions sign on the client's door. Which side effects of morphine could contribute to this client's fall risk? Select all that apply