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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 B

Explanation

A. Insomnia may occur while taking the medication: St. John's wort can increase central nervous system stimulation, leading to side effects like insomnia, restlessness, and anxiety. Educating the client that sleep disturbances may occur is appropriate and consistent with known herb effects.

B. Another form of contraception is not needed: St. John's wort can induce cytochrome P450 enzymes, leading to faster metabolism and reduced effectiveness of hormonal contraceptives like birth control pills. Clients must be advised to use an additional non-hormonal contraceptive method to prevent unintended pregnancy.

C. Hard candy can be used for a dry mouth: Dry mouth is a recognized side effect of St. John's wort. Sucking on hard candy, increasing oral hydration, or chewing sugarless gum are appropriate and effective ways to manage this discomfort.

D. Sensitivity to the sun can develop: Photosensitivity is a well-documented adverse effect of St. John's wort. Clients should be instructed to use sunscreen, wear protective clothing, and limit sun exposure to prevent sunburns or skin reactions.

A. Dry mouth, blurred vision, and constipation. B. Headache, jaundice, and diarrhea. C. Bradycardia, delirium, and sedation. D. Insomnia, hypertension, and vomiting.

Correct Answer is A

Explanation

A. Dry mouth, blurred vision, and constipation: These symptoms are classic anticholinergic side effects associated with many antidepressants, especially tricyclic antidepressants (TCAs). They result from the blockade of muscarinic receptors and are frequently reported by clients receiving these medications.

B. Headache, jaundice, and diarrhea: While headaches can occur with antidepressant use, jaundice is rare and would suggest serious liver toxicity rather than a common side effect. Diarrhea may happen with selective serotonin reuptake inhibitors (SSRIs) but is less typical overall than anticholinergic symptoms.

C. Bradycardia, delirium, and sedation: Some antidepressants can cause sedation, but bradycardia and delirium are not common side effects across the entire antidepressant class. These would be more likely associated with toxicity or drug interactions rather than typical daily use.

D. Insomnia, hypertension, and vomiting: Insomnia can occur with certain antidepressants like SSRIs or SNRIs, but hypertension and vomiting are less consistently seen across all antidepressant classes. These symptoms are not considered the hallmark side effects of antidepressant therapy.

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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

A female client with mild depression reports to the nurse recently starting St. John's wort. Which information provided by the client requires further instruction?

Correct Answer is B

Explanation

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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

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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