Your 95-year-old client's vital signs are as follows: oral T 98.6 F: P (radial) 84 with irregularity: R 18. normal depth, & regular: BP (left arm, sitting) 140/86. Which nursing assessment(s) would be done to obtain more data at this time?

Positional BP readings

Carotid pulse and temperature

Full respiratory system assessment

Apical pulse for one minute

Answer and Explanation

The Correct Answer is D

A. Positional BP readings. While orthostatic blood pressure readings can assess for postural hypotension, there is no indication in the current vitals that the client is experiencing symptoms such as dizziness or syncope.
B. Carotid pulse and temperature. The client’s temperature is already documented as normal, and the carotid pulse is not needed when an irregular radial pulse has been noted. The apical pulse is the preferred method to assess for irregularities.
C. Full respiratory system assessment. The respiratory rate is within the normal range, with regular rhythm and normal depth, so a full respiratory assessment is not the immediate priority.
D. Apical pulse for one minute. An irregular radial pulse suggests the possibility of an arrhythmia. The apical pulse provides a more accurate assessment of heart rhythm and rate, ensuring a complete evaluation of the irregularity.

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Correct Answer is D

Explanation

A. Irritating cough. Opioid agonists do not typically cause an irritating cough. In fact, opioids like codeine are used as antitussives to suppress cough reflexes.
B. Tachypnea. Opioids depress the central nervous system, leading to respiratory depression rather than an increased respiratory rate (tachypnea). The nurse should monitor for bradypnea instead.
C. Hypertension. Opioids commonly cause hypotension due to vasodilation and central nervous system depression. Hypertension is not a typical adverse effect.
D. Urinary retention. Opioids can increase sphincter tone and suppress the urge to void, leading to urinary retention. This is a known side effect and should be monitored, especially in older adults or those with underlying bladder issues.

A. "Don't worry. The cancer prevents you from becoming addicted." B. "That is a valid worry. I wouldn't want to become addicted." C. "My cousin was addicted to pain killers when he had cancer." D. Because you have severe pain, the medication is necessary. There is little chance of addiction as long as you take the medication as prescribed.

Correct Answer is D

Explanation

A. "Don't worry. The cancer prevents you from becoming addicted." This statement is incorrect because having cancer does not prevent addiction. However, appropriate pain management in patients with severe pain does not typically lead to addiction.
B. "That is a valid worry. I wouldn't want to become addicted." While acknowledging the patient’s concern is important, this response reinforces fear rather than providing reassurance based on medical evidence.
C. "My cousin was addicted to pain killers when he had cancer." This response is inappropriate because it is anecdotal and does not address the patient’s concern with factual medical information.
D. "Because you have severe pain, the medication is necessary. There is little chance of addiction as long as you take the medication as prescribed." This is the best response because it reassures the patient that pain control is a priority and that, when used correctly, the risk of addiction is minimal.

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Your 95-year-old client's vital signs are as follows: oral T 98.6 F: P (radial) 84 with irregularity: R 18. normal depth, & regular: BP (left arm, sitting) 140/86. Which nursing assessment(s) would be done to obtain more data at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an opioid agonist to a client who has acute pain. For which of the following manifestations should the nurse monitor as an adverse effect of this medication?

Correct Answer is D

Explanation

Exhibits Mrs. Watson tells Lana that she is worried about getting addicted to the morphine because she has heard that it can happen. How should Lana respond? (Case Study #2)

Correct Answer is D

Explanation

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