You Selected: • The client has developed tolerance to the dose of morphine. Correct response: • The client has developed tolerance to the dose of morphine. Explanation: Tolerance to a regular opioid dose can develop with frequent use. The client experiences increased discomfort, asks for medication more frequently, and exhibits anxious and restless behavior, actions which are often misinterpreted as indicative of developing dependence or addiction. The client’s symptoms do not suggest that the dosage is too high. Addiction is a psychological condition in which a client takes drugs for nontherapeutic reasons. This client is receiving morphine for pain control. There are no data given about the client’s coping mechanisms. Question 11 A client is receiving cyclobenzaprine for management of a herniated lumbar disk. Which finding indicates the drug is providing the intended relief? You Selected: • The client’s muscles are not in spasm. Correct response: • The client’s muscles are not in spasm. Explanation: Cyclobenzaprine is a muscle relaxant, given to relieve muscle spasm and the related pain. Cyclobenzaprine does not have an effect on the client’s ability to take deep
breaths. Sedatives and tranquilizers are not typically used in the conservative treatment of herniated lumbar disks. Question 12 After the client returns from surgery for a deviated nasal septum, the nurse should place the client in what position? You Selected: • left side lying Correct response: • semi-Fowler’s Explanation: To assist in breathing, promote comfort, and decrease edema formation after surgery, the client is most appropriately placed in semi-Fowler’s position. The supine position will result in increased swelling, which will increase pain and interfere with breathing. Lying on either side will increase dependent swelling. Reverse Trendelenburg’s provides no advantages over semi-Fowler’s. Question 13 Which measure would be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery? You Selected: • Apply ice compresses. Correct response: • Apply ice compresses. Explanation: The most effective way to decrease discomfort is to decrease local edema. Cold application, such as an ice compress or ice bag, is effective. Heat dilates local vessels and increases local congestion. Semi-Fowler’s position helps decrease edema and prevents aspiration. Nose blowing should be avoided for at least 48 hours after the nasal packing is removed because it can disrupt the surgical site and lead to bleeding. Question 14 The nurse is instructing a client with Ménière’s disease how to recognize vertigo. The nurse should tell the client to notice: You Selected: • a feeling that the environment is in motion. Correct response: • a feeling that the environment is in motion.
- Spring '17
- mrs. Vargovich
- Nursing, Intracranial pressure, Traumatic brain injury, Cerebrospinal fluid, Correct Response