The nurse is evaluating the client’s response to pain management.
Click to highlight the findings that indicate the client is experiencing the therapeutic effects of the medication.
Pain level presently 3 on a 0 to 10 scale. The client reports feeling "sleepy." Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer. New mild cough noted. Repositions in bed with minimal assistance. Attempted to get up to the chair, but experienced dizziness with standing.
Pain level presently 3 on a 0 to 10 scale
The client reports feeling "sleepy."
Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer.
New mild cough noted.
Repositions in bed with minimal assistance.
Attempted to get up to the chair, but experienced dizziness with standing.
The Correct Answer is ["A","C","E"]
Rationale for correct choices:
• Pain level presently 3 on a 0 to 10 scale: A reduction in pain from 8/10 to 3/10 indicates that the morphine is effectively alleviating the client’s pain. Effective analgesia allows for improved comfort, participation in breathing exercises, and reduced stress response.
• Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer: Increased inspiratory volume demonstrates improved lung expansion, indicating that pain control is facilitating better respiratory effort. This is especially important to prevent atelectasis and maintain adequate oxygenation after rib fractures.
• Repositions in bed with minimal assistance: Ability to move with less assistance reflects improved comfort and mobility due to effective pain management. This shows the therapeutic effect of analgesia in enabling functional activity without excessive pain.
Rationale for incorrect choices:
• Client reports feeling "sleepy": Sleepiness is a common side effect of morphine, reflecting central nervous system depression rather than a therapeutic effect of pain relief. While mild sedation can accompany effective analgesia, it does not directly indicate improvement in the underlying condition.
• New mild cough noted: The appearance of a new cough is not a direct indicator of therapeutic pain relief. It may reflect airway irritation, increased secretions, or a response to deeper breathing, but it is not a measure of analgesic effectiveness.
• Attempted to get up to the chair, but experienced dizziness with standing: Dizziness indicates a side effect of the opioid (orthostatic hypotension or sedation), not a therapeutic response. This finding requires monitoring and safety interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Continue PROM if joint's muscle spasms to relax muscle: Continuing to move a joint during muscle spasms can worsen injury or cause pain. PROM should be stopped if spasms occur and reassessed to prevent harm.
B. Slowly stretch the joint's muscles if pain is present: Stretching a joint when pain is present can cause tissue damage or exacerbate injury. Pain indicates that the joint has reached its limit, so exercises should be within a pain-free range.
C. Move the joint slowly until resistance is felt: Moving the joint slowly until resistance allows for safe assessment of mobility and flexibility without overstretching or causing injury. Resistance provides a natural limit to the joint’s passive range of motion.
D. Instruct the client to relax during the exercises: Relaxation reduces muscle tension, allowing for safer and more effective passive movements. Client cooperation helps prevent muscle guarding and ensures proper joint mobilization.
E. Support the extremity of the joint being exercised: Supporting the extremity prevents undue stress on muscles and joints, reduces the risk of injury, and allows controlled movement during PROM exercises. Proper support is essential for safety.
Correct Answer is ["A","B","C","D"]
Explanation
A. Nausea and vomiting: Gastrointestinal symptoms such as nausea, vomiting, and anorexia are common early signs of digoxin toxicity and should be closely monitored.
B. Fatigue and weakness: Generalized fatigue and muscle weakness can result from digoxin toxicity due to its effects on cardiac output and electrolyte imbalances, indicating early toxicity.
C. Bradycardia: Digoxin increases vagal tone, which can lead to bradycardia. A heart rate below 60 bpm is a key warning sign of digoxin toxicity.
D. Visual disturbances (e.g., yellow-green halos): Visual changes, including blurred vision, yellow-green halos, or altered color perception, are classic manifestations of digoxin toxicity and require prompt recognition.
E. Hypertension: Hypertension is not typically associated with digoxin toxicity; digoxin more commonly causes bradyarrhythmias and hypotension rather than elevated blood pressure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.