Which action should the nurse take to assess for analgesic tolerance in a client who is unable to communicate?

Observe the client for the presence of pain behaviors before the next analgesic dose is due.

Review the client's laboratory values for a change in the peak and trough levels of the analgesic

Prolong the interval between analgesic medication doses and monitor the client's vital signs.

Ask family members to report behaviors suggesting that the client's pain has returned.

Answer and Explanation

The Correct Answer is A

A. Observe the client for the presence of pain behaviors before the next analgesic dose is due: In a nonverbal client, observing for pain behaviors such as grimacing, restlessness, moaning, or changes in vital signs is crucial. If these behaviors increase before the next scheduled dose, it may suggest that the current analgesic regimen is becoming less effective, indicating tolerance.

B. Review the client's laboratory values for a change in the peak and trough levels of the analgesic: Peak and trough levels are useful for monitoring therapeutic ranges for certain medications but are not reliable indicators of analgesic tolerance. Tolerance is a clinical observation based on pain behavior, not solely on drug concentration measurements.

C. Prolong the interval between analgesic medication doses and monitor the client's vital signs: Extending the interval between doses risks undertreating the client’s pain and causing unnecessary suffering. Tolerance assessment should focus on evaluating pain control, not withholding medication to observe physiological responses.

D. Ask family members to report behaviors suggesting that the client's pain has returned: While family members can provide valuable insight, their observations should supplement, not replace, the nurse's direct clinical assessment. Family members may miss subtle signs of pain or misinterpret behaviors unrelated to pain.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"A"}

Explanation

Pure opioid agonist: Morphine is classified as a pure opioid agonist because it fully binds and activates opioid receptors, particularly mu receptors, producing maximum analgesic effects for moderate to severe pain management.
Mixed opioid antagonist: Mixed opioid antagonists, like nalbuphine, both activate and block opioid receptors depending on the site. Morphine does not block opioid activity; it purely stimulates, making this choice incorrect.
Non-opioid analgesic: Non-opioid analgesics, such as acetaminophen and NSAIDs, relieve mild to moderate pain without acting on opioid receptors. Morphine’s mechanism and use are specific to the opioid class.
Partial opioid agonist: Partial agonists, such as buprenorphine, activate opioid receptors but produce a weaker response compared to pure agonists. Morphine elicits a full receptor response, differentiating it from partial agonists.
Mu: Mu receptors are the primary opioid receptors activated by morphine, leading to effects such as analgesia, euphoria, respiratory depression, and decreased gastrointestinal motility.
Beta: Beta receptors are adrenergic receptors involved in cardiovascular responses, not pain modulation. Morphine does not interact with beta receptors.
Alpha: Alpha receptors are also part of the adrenergic system and regulate vascular tone and blood pressure. Morphine’s action is not through alpha receptor activation.
Severe pain: Morphine is most commonly used to treat moderate to severe acute or chronic pain, especially postoperative pain, cancer pain, and trauma-related injuries requiring strong opioid therapy.
Hypertension: Morphine is not indicated for treating hypertension. While it may indirectly lower blood pressure due to vasodilation and reduced sympathetic tone, it is not a therapeutic antihypertensive agent.
Depression: Morphine is not used for managing depression. Although it can induce feelings of euphoria, its clinical use is strictly for pain relief, not mood disorders.

A. Midmorning B. Shortly after midnight C. No peak occurs. D. Midafternoon.

Correct Answer is C

Explanation

A. Midmorning: Short-acting and some intermediate-acting insulins peak during midmorning, but glargine insulin is long-acting and designed to provide a steady level of insulin without a pronounced peak, making midmorning hypoglycemia unlikely.

B. Shortly after midnight: Although nighttime hypoglycemia can occur with other types of insulin, glargine releases slowly over 24 hours, maintaining a relatively flat serum insulin concentration and reducing the risk of nocturnal hypoglycemia.

C. No peak occurs: Glargine insulin is formulated to have no pronounced peak, instead providing a continuous, steady release over approximately 24 hours. This flat profile minimizes the risk of sudden hypoglycemic episodes associated with peak insulin levels.

D. Midafternoon: Hypoglycemia during midafternoon is more characteristic of short-acting or intermediate-acting insulins, not glargine. Since glargine has a steady release, it does not typically cause time-specific hypoglycemia like shorter-acting insulins do.

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Which action should the nurse take to assess for analgesic tolerance in a client who is unable to communicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"A"}

Explanation

The nurse is teaching a client with type 1 diabetes mellitus about the onset, peak, and duration of a new prescription for glargine insulin. If the insulin is self administered at 0800, when is the client most likely to experience hypoglycemia?

Correct Answer is C

Explanation

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