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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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Notify the healthcare provider (HCP) that the client may need a change in dosage: Lansoprazole, a proton pump inhibitor, requires several weeks of continuous use to promote sufficient healing of erosive esophagitis. Reporting to the provider after just one week would be premature unless severe symptoms worsen.

B. Advise the client that healing typically takes several weeks to occur: Full therapeutic effects of proton pump inhibitors like lansoprazole can take 4 to 8 weeks. Educating the client about the expected treatment timeline helps set realistic expectations and encourages adherence to the prescribed regimen.

C. Confirm that the client is taking the medication one hour after meals: Lansoprazole should be taken before meals, not after, to inhibit active proton pumps in the stomach lining. However, the primary concern here is the normal expected time course for healing, not the timing of the dose in relation to meals.

D. Auscultate the client's bowel sounds and measure the abdominal girth: Monitoring for bowel issues would be relevant if there were signs of gastrointestinal complications like obstruction or perforation, but these assessments are not indicated by the client’s report of minimal GERD symptom improvement after only one week.

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

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Correct Answer is B

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