PrepU Chapter 26

A hospice patient has been ordered morphine (Roxanol) 5 mg every 2 hours. Roxanol contains 10 mg/mL. How many mL will be administered?

0.5 mL 5 mg/X=10 mg/mL. The calculation results in .5 mL. The administration of 0.25, 1, or 2 mL is incorrect.

The nurse observes that a new client's medication regimen includes sumatriptan. What assessment should the nurse prioritize?

Assessing the client for migraine pain Sumatriptan is indicated for the treatment of acute migraine and cluster headaches. As such, the nurse should assess the client for indications of this health problem, more so than respiratory status or blood pressure. Narcotic withdrawal syndrome is unrelated.

The nurse is giving instructions to a client who has just been prescribed sumatriptan for the treatment of migraine headaches. The client will be instructed to take this medication at what time?

At the onset of migraine symptoms Sumatriptan should be taken at the onset of migraine symptoms.

A patient is prescribed opioid analgesic. During the initial interview with the patient, the nurse understands that the patient chronically drinks alcohol. Which effect of the interaction between opioid analgesic and alcohol should the nurse monitor for in the patient?

Central nervous system depression The nurse should monitor the patient for central nervous system depression. The nurse need not monitor the patient for respiratory depression, hypotension, and sedation because these are the effects of interaction of opioid analgesic with barbiturates, not alcohol.

The nurse works in a long-term care facility. When administering narcotics to clients, the nurse must monitor for which side effect?

Constipation Morphine and other opiates delay stomach emptying and slow peristalsis. They can be used to treat severe diarrhea or for surgical interventions involving the intestines. However, this slowed peristalsis can also cause constipation (a very common side effect), abdominal pain, and distention. Sleep deprivation, bleeding and diarrhea are not normal side effects.

The client has difficulty swallowing and requests the nurse to crush all the medications. The nurse notes a client prescribed an extended-release opioid requests that all medications be crushed to facilitate the administration. What information about this form of opioid presents a problem respecting the client's request?

Crushing the medication may precipitate an overdose. Health care providers and clients must be cautioned to avoid crushing or chewing the tablets or opening capsules because immediate release of the drug constitutes an overdose. None of the other answers apply.

A nurse is assessing a client's pain level. Which would be the most appropriate method?

Have the client rate it on a scale of 1 to 10. The most appropriate method for assessing pain is to have the client rate his pain by using some type of scale. This provides objective evidence of the severity of the pain and provides a basis for comparison later on.

A client diagnosed with a migraine has been prescribed naproxen. What is the nurse's priority when the client reports being allergic to aspirin?

Hold the medication. The nurse's priority is to hold the medication. Contraindications to naproxen or naproxen sodium include a known allergy to aspirin or other nonsteroidal anti-inflammatory drugs. The nurse should not discuss this with the client but with the prescriber. The nurse should not give the medication or call the pharmacy for clarification.

Although naloxone is given to counter opioid medication side effects such as respiratory depression, what additional issues (if any) may result from administration of an opioid antagonist?

Increase in the client's pain rating An opioid antagonist will counter not only the negative effects of an opioid medication but the beneficial effects of the opioid (such as pain relief) as well, resulting in an increase in the client's pain rating. It would not result in a decrease or lack of change in the pain rating.

Which statement best describes a drug's characteristic of having no ceiling effect?

It is a valuable drug to use because dosage can be increased to relieve pain when pain increases or tolerance develops. A drug with no ceiling effect is one in which there is no upper limit to the dosage that can be given to clients who have developed tolerance to previous dosages. This characteristic is especially valuable in clients with severe cancer-related pain because drug dosage can be increased and titrated to relieve pain when pain increases or tolerance develops.

Which medications are opioids for which naloxone may be given to counter the effects?

Meperidine Meperidine is an opioid medication for which naloxone is an opioid antagonist, and for which naloxone counters the effects. Acetaminophen is not an opioid medication and naloxone would have no effect on a client receiving this medication. Ibuprofen and naproxen are nonsteroidal anti-inflammatory drugs, and naloxone would have no effect on a client receiving these medications.

A client is undergoing inpatient addiction rehabilitation following many years or addiction to heroin. What medication would be the most useful adjunct to treatment?

Methadone Methadone is used for detoxification and temporary maintenance treatment of narcotic addiction. Oxycodone is used for the relief of moderate to severe pain in adults. Oxymorphone is used for the relief of moderate to severe pain in adults, preoperative medication, and obstetrical analgesia. Tramadol is used for the relief of moderate to moderately severe pain, and its use should be limited in clients with a history of addiction.

A nurse has entered a client's room at the beginning of a shift to quickly assess the clent's airway, breathing, circulation, and consciousness. The nurse observes that the client is wincing, stating, " Oh, I am in so much pain right now." What initial question should the nurse ask this client?

"Where exactly are you hurting?" To begin the pain assessment, first determine the location of the pain. Location gives possible clues to the source of the pain and can help identify whether the pain is acute or of a more chronic nature. Questions about preferred treatments and the timing of the pain are appropriate and important, but it is normally necessary to first ascertain the location of the client's pain.

The nurse is caring for a patient who is suffering from postoperative pain. The physician orders 2.5 mg of morphine IV q2h. Morphine is supplied in 10 mg/mL vials. How many mL will the nurse administer in each dose?

0.25 mL

The health care provider has ordered 0.2 mg naloxone to be administered intramuscularly stat. The pharmacy has available naloxone 0.4 mg/mL. How much naloxone will the nurse administer to the client?

0.5

When administering an opioid antagonist drug to a client, the primary goal of the therapy is to provide:

a return to normal respiratory rate, rhythm, and depth. The primary reason for administering an opioid antagonist is because the client is experiencing respiratory depression. Therefore, the goal is to improve the client's respiratory rate, rhythm, and depth. None of the other options is part of the drug therapy.

The client is to take almotriptan 6.25 mg orally for a migraine. Almotriptan is sent to the unit from the pharmacy in 12.5-mg tablets. The nurse will administer how many tablet(s)?

0.5 6.25/12.5 = 0.5 or 1/2 tablet

A client has been prescribed morphine 4 - 6 mg IV q4h PRN. The client reports pain rated at 8/10 and the nurse verifies on the MAR that the client has most often required 6-mg doses. The nurse chooses to administer 6 mg. The drug is available in ampules containing 10mg/mL. How many mL should the nurse withdraw and administer?

0.6

A client has been prescribed morphine 4 - 6 mg IV q4h PRN. The client reports pain rated at 8/10 and the nurse verifies on the MAR that the client has most often required 6-mg doses. The nurse chooses to administer 6 mg. The drug is available in ampules containing 10mg/mL. How many mL should the nurse withdraw and administer?

0.6 6 mg ÷ 10 mg/mL = 0.6 mL

When describing the onset of action of naloxone, the nurse would explain that the drug achieves its effect in which amount of time?

1 to 2 minutes Naloxone is capable of restoring respiratory function within 1 to 2 minutes of administration. The shorter the time to restoring respiration the less time the client has to depend on manual or mechanical ventilation and the better the outcome for the client.

The nurse administers morphine 15 mg oral solution to a client with cancer pain at 0930. When should the nurse reassess the client for peak effect?

1030 With oral administration, peak activity occurs in about 60 minutes. The duration of action is 5 to 7 hours.

Naloxone 2 mg IM has been ordered for a post surgical client. The pharmacy has sent to the floor naloxone 1 mg/mL. How much naloxone will the client receive?

2 The nurse is to administer 2 mg of naloxone. The pharmacy has supplied 1 mg/1 mL. Therefore, in order to administer 2 mg, the nurse must administer 2 mL.

Following the subcutaneous (subcut) administration of pain medication, the nurse would know to check the client's vital signs in what amount of time?

20-30 minutes Vital signs should be taken within 20 to 30 minutes after intramuscular (IM) or subcutaneous (subcut) medication administration. Vital signs should be taken within 5 to 10 minutes following intravenous (IV) administration, and 30 or more minutes following oral administration.

The nurse knows that, of the following clients, who is least likely to be prescribed transdermal fentanyl?

A woman 85 years of age The transdermal route of medication administration is dependent upon the amount of subcutaneous tissue present for medication distribution. Subcutaneous tissue is reduced as a result of the aging process. Therefore, the client 85 years of age would be least likely to be prescribed a transdermal medication. The clients 25, 35 and 50 years of age would have adequate subcutaneous tissue for medication distribution.

A client's healthcare provider has prescribed meperidine 75 mg PO q4h PRN for the client's chronic pain. What education should the nurse provide to this client reagarding this medication?

"Avoid drinking alcohol while taking meperidine." Drinking alcohol during narcotic treatment can exacerbate CNS depression. Narcotics do not necessitate monitoring of serum levels and they do not cause photosensitivity. Most clients do not experience significant dyspepsia; constipation is by far the most common GI effect.

A client prescribed sumatriptan as abortive therapy for migraines reports, "I took that pill about an hour-and-a-half ago, and I still don't feel any better. Can I take another?" How should the nurse respond?

"Wait at least half-an-hour before you take another pill." Administration of a second dose of the oral preparation of sumatriptan when symptoms return is acceptable but not earlier than 2 hours after the first tablet.

The nurse administers an oral opioid analgesic to a client at 6 PM for pain documented as 6 on a scale of 0 to 10. At 6:30 PM, the client states that the pain level is 3 on a scale of 0 to 10, and that level is acceptable to him. The client asks the nurse why another assessment was necessary after the administration of the pain medication. What is the nurse's best response to this client about proper pain management?

"We assess every client in relation to pain, initially to determine appropriate interventions and later to determine whether the interventions were effective in preventing or relieving pain." The nurse must assess every client in relation to pain, initially to determine appropriate interventions and later to determine whether the interventions were effective in preventing or relieving pain.

A 40-year-old male client with arthritis of the knee joint has been prescribed an analgesic to relieve the pain. Which medication is a narcotic analgesic?

Morphine Morphine is a narcotic analgesic. Aspirin, ibuprofen, and celecoxib are nonnarcotic analgesics. Aspirin is classified as a salicylate and ibuprofen as a nonsteroidal anti-inflammatory drug (NSAID). Celecoxib is a newer NSAID that acts by inhibiting the cyclo-oxygenase-2 (COX-2) enzyme.

The client returns from the post-anesthesia recovery unit. The nurse notes a respiratory rate of 6. Which drug would the nurse anticipate being given immediately?

Narcan Narcan has long been the drug of choice to treat respiratory depression caused by an opioid. Therapeutic effects occur within minutes after IV, IM, or sub-q injection and last 1 to 2 hours.

A nurse is caring for a client diagnosed with a migraine. The client received acetaminophen-aspirin-caffeine by mouth. Which method should be used to assess for the therapeutic effects of the medication?

Pain scale Following the administration of the acetaminophen-aspirin-caffeine combination, the client should exhibit diminished pain. The nurse assesses for pain using the pain scale. Vital signs do not always align with the pain the client is experiencing. The Glasgow coma scale assesses neurologic function and not pain. The subjective assessment can accompany the pain scale to determine and document exactly what the client states.

The client has had a myocardial infarction. The nurse is administering morphine sulfate for the pain. What vital sign would the nurse monitor that directly relates to the use of this narcotic?

Respiratory rate The first sign of narcotic overdose is often respiratory depression. Therefore, monitoring the client's vital signs, particularly respirations, is extremely important when administering narcotics.

The nurse is administering opioid analgesics to a client for postoperative pain. What is the nurse's most important assessment prior to administering the medication?

Respiratory rate The most important assessment that the nurse can make prior to administration of an opioid is the respiratory rate because the most serious adverse complication of opioid use is respiratory depression.

Opioids exert widespread pharmacologic effects, especially in the CNS and the gastrointestinal (GI) system. What are two major adverse effects of opioids that are potentially life threatening?

Sedation and respiratory depression CNS effects include analgesia; CNS depression, ranging from drowsiness to sleep to unconsciousness; decreased mental and physical activity; respiratory depression; nausea and vomiting; and pupil constriction. Sedation and respiratory depression are major adverse effects and are potentially life threatening.

Which assessment finding would support a client's report of migraine headaches?

Severe unilateral pulsating pain Migraine headaches are associated with severe unilateral pulsating pain on one side of the head. Sharp steady eye pain with an onset usually during sleep is associated with cluster headaches. A dull band of pain around the head suggests a tension headache.

In order to maximize therapeutic benefit while reducing the risk of adverse effects of sumatriptan, the nurse should encourage the client to implement which intervention?

Take the medication as soon as the earliest symptoms of migraine are sensed.

Naproxen has been prescribed to a client whose increasingly severe migraines are interfering with work performance and family life. When providing health education to this client, the nurse should instruct the client to consider what intervention?

Take the pills with meals to minimize stomach upset. Naproxen should be taken on a full stomach. The pills should not be crushed. Constipation is not a noted adverse effect, and regular blood work is not warranted.

Which information presented in the client's history should prompt the nurse to discourage a client from self-medicating with an over-the-counter (OTC) acetaminophen, aspirin, and caffeine combination drug?

The client has a diagnosis of liver cirrhosis. Clients diagnosed with hepatic impairment should not receive this combination agent on an ongoing basis. They may not metabolize acetaminophen in this combined medication effectively, leading to hepatotoxicity. Lack of previous adherence, cigarette smoking, and the presence of skin ulcers do not necessarily contraindicate the use of this drug.

Opioid receptors are highly concentrated in some regions of the central nervous system, including the ascending and descending pain pathways and portions of the brain essential to the endogenous analgesia system.

True Opioid receptors are highly concentrated in some regions of the central nervous system, including the ascending and descending pain pathways and portions of the brain essential to the endogenous analgesia system.

What is the most effective way to evaluate the pain response after administering a nonopioid analgesic?

Using a pain scale, ask the patient to describe the pain.

The nurse has just administered an opioid antagonist to a client who had been experiencing respiratory depression. How soon can the nurse expect to see improvement in the client's respiratory function?

Within one to five minutes, an effect may be seen. Onset of action is generally rapid and may be seen within one to five minutes. Additional doses may be required to achieve optimal effects. The other answers are incorrect because they are referring to a time later than onset of action, or refer to a conditional onset of action that is untrue.

When diagnostic testing reveals a bone fracture, what type of pain is the client experiencing?

acute somatic pain Sprains and other traumatic injuries are examples of acute somatic pain. Somatic pain results from stimulation of nociceptors in the skin, bone, muscle, and soft tissue. Visceral pain, which is diffuse and not well localized, results when nociceptors are stimulated in abdominal or thoracic organs and their surrounding tissues either from acute or chronic injuries. Neuropathic pain is caused by lesions or physiologic changes that injure peripheral pain receptors, nerves, or the central nervous system.

A trauma client has been receiving frequent doses of morphine in the 6 days since his accident. This pattern of analgesic administration should prompt the nurse to carefully monitor the client's what?

bowel patterns Morphine, like most opioid analgesics, creates a risk for constipation. The drug is unlikely to influence the client's temperature, skin integrity, or urine specific gravity.

A nurse is teaching a client about her prescription for acetaminophen that she will take at home. This medication consists of acetaminophen and what other likely drug that enhances the analgesic effect of acetaminophen?

codeine Codeine is often given with acetaminophen for additive analgesic effects. None of the other medications are used in combination with acetaminophen.

A client is to receive a narcotic cough syrup. The nurse would expect this preparation to contain:

codeine Typically, codeine or hydrocodone are used to relieve coughing.

Which client would the nurse identify as being opioid naive?

one who does not routinely take opioids Opioid-naive clients are defined as those who do not use opioids or infrequently use them. Those who routinely take and are physically or psychologically dependent on opioids are not considered opioid naive.

Opioid antagonists may produce withdrawal symptoms in clients physically dependent on which substance?

opiods Opioid antagonists may produce withdrawal symptoms in clients physically dependent on opioids. Naloxone has no effect on benzodiazepines, alcohol, or NSAIDs.

A client is receiving opioid therapy. The nurse should be alert to the possibility that which could occur if the client receives an opioid agonist-antagonist?

opioid withdrawal symptoms The nurse should know that the interaction of opioid analgesics with an opioid agonist-antagonist will lead to opioid withdrawal symptoms in clients. Increased risk for CNS depression occurs when opioid analgesics interact with antihistamines, antidepressants, sedatives, and phenothiazines. Respiratory depression and hypotension occur when opioid analgesics interact with barbiturates.

A client is prescribed zolmitriptan for migraine headaches. The nurse should instruct the client to administer this drug by which route?

oral Zolmitriptan is administered orally only.

A nurse is caring for a 49-year-old client in the intensive care unit. The client was in a motor vehicle accident and is in severe pain. The client has been given morphine. After 2 days in the unit, the nurse can detect nasal congestion when the client speaks to her. The nurse will monitor for which?

pneumonia Respiratory depression is a common adverse effect of morphine. If the client gets a cold, as the nasal congestion can be a sign, this respiratory depression could cause retained secretions and put the client at greater risk for developing pneumonia. The drug does not cause myocardial infarction or renal impairment. A common cold is not known to cause hypersensitivity to the morphine.

Which conditions would occur due to the administration of an opioid antagonist in a client who is physically dependent on opioids?

withdrawal symptoms Opioid antagonists produce withdrawal symptoms in clients who are physically dependent on opioids. Drowsiness, hypotension, and insomnia do not occur in opioid-dependent clients who are administered opioid antagonists.

A client is prescribed sumatriptan. Which statement should be included in the teaching plan regarding how the medication works?

"It produces vascular constriction of cranial blood vessels." Sumatriptan binds to the serotonin receptors 5-HT1D, producing vascular constriction of the cranial blood vessels and relieving the pain of a migraine headache. It also relieves the nausea, vomiting, photophobia, and phonophobia that accompany the migraine headache. Sumatriptan does not cause bronchiole constriction or impair the reuptake of norepinephrine. It does not relax smooth muscles of the cardiovascular system.

The male client states that he does not have a back injury and that it is his leg that hurts. He feels every one is not listening to him. What is the best response by the nurse?

"Sometimes when there is nerve damage, it shows up as pain in a different part of the body." Neuropathic pain refers to pain caused by nerve damage rather than by tissue injury or damage. It often is demonstrated through referred pain. Telling the client he has been misdiagnosed is inappropriate. The nurse cannot diagnose the disease process.

A 50-year-old woman has been prescribed sumatriptan for the treatment of migraines. What instructions should then the nurse provide to the patient about the safe and effective use of this drug?

"Take this drug as soon as you feel the first signs of a migraine." Administer sumatriptan as soon as the headache begins. Sumatriptan is more efficacious when given before the headache escalates. However, it is not normally taken on a prophylactic basis.

A client's family asks why the nurse has placed suction equipment in the room immediately after administering a dose of naloxone. Which explanation by the nurse is correct?

Abrupt reversal of opioid-induced respiratory depression may cause vomiting. It is important to keep suction equipment readily available because abrupt reversal of opioid-induced respiratory depression may cause vomiting. None of the other rationales provided is a valid reason for adding suction equipment to the room of a client who requires a dose of naloxone.

The nurse is caring for a postoperative client taking an opioid medication for pain. The nurse assesses the client to have bradypnoea and an oxygen saturation value of 90%. Which actions should the nurse perform before administering the ordered opioid antagonist?

Assess the client's other vital signs. Blood pressure, pulse, and respirations are important assessments to make prior to administering an opioid antagonist. It is unnecessary to call for a respiratory therapy consult because the cause of the respiratory depression is known. While assessing and managing pain are important postoperative interventions, the respiratory depression-management interventions are the most important ones to be addressed.

The nurse enters the client's room to see how the client's pain level is because PRN demerol can be given. The client is sitting up in bed laughing and visiting with family. The client states that the pain is a "10" on a pain scale of 0 to 10. What is the best response by the nurse?

Administer the pain medication as ordered. Pain is what the client says it is. If the client states pain is a "10" and is requesting medication, the nurse should medicate as per orders. The client laughing and visiting may be a method of coping with the pain. The nurse should demonstrate a nonjudgmental attitude to build a trusting relationship. The nurse cannot alter the dosage of medication without consulting the health care provider.

The client is having surgery this week. What information should the nurse give the client concerning the use of pain medication after surgery?

Ask for pain medication before the pain gets severe. The nurse should emphasize the importance of pain control, stressing to the client that pain relief is greater if the medication is taken when pain is not very severe. If the client waits too long for pain medication, it will be much harder to control the pain. Also, the client should not take pain medication whenever it is available, but only when it is needed. It is rare for a client to become addicted to pain medication when it is taken for the relief of pain. The need for the pain medication goes away when the pain subsides.

How will a client's impaired renal function affect the pharmacokinetics of morphine?

Duration of action will be prolonged. Clients with renal impairment should take minimal doses of morphine for the shortest effective time because usual doses may produce profound sedation and a prolonged duration of action. Neither desired effect, onset, nor peak are the concerns.

A client is to receive a narcotic that will be applied transdermally. The nurse identifies this as which agent?

Fentanyl Fentanyl is available as a transdermal patch.

Naloxone (Narcan) will reverse the effects of which drug?

Fentanyl (Duragesic) Naloxone (Narcan) is an opioid antagonist, which means it will only reverse the effects of opioids like fentanyl (Duragesic).

What action should the nurse take when administering meperidine 75 mg IM every 4 hours to a young adult?

Give the medication as prescribed. The client should be administered the full dose of medication, which is within dosing recommendations. A client with adequate hepatic and renal function should not receive a lower dose of meperidine without specific instruction from the prescribing care provider. There is no apparent reason to change the route of administration, and such action cannot be implemented without the instruction of the prescribing care provider.

Prior to administering morphine, the nurse checks the client's medication history. The nurse will contact the health care provider and hold the morphine if the nurse notes the client is currently taking which medication?

Monoamine oxidase (MAO) inhibitor The client should not receive morphine within 14 days of receiving an MOA inhibitor.

Both categories of migraine abortive drugs (ergot alkaloids and serotonin agonists) exert powerful vasoconstrictive effects and also have what potential?

Raise blood pressure Both categories of migraine abortive drugs (e.g., ergot alkaloids and serotonin agonists) exert powerful vasoconstrictive effects and have the potential to raise blood pressure.

A client admitted to the emergency department with a migraine headache unrelieved with current prescribed medications. The nurse administers prescribed ketorolac tromethamine 30 mg IV and metoclopramide 10 mg IV, and the client suddenly develops involuntary movement of upper limbs, facial grimacing, sticking out the tongue rhythmically, contractures of the neck and head to one side in a twisting motion, and rapid involuntary spasms of eyelids. Which action would the nurse implement first?

Receive order for diphenhydramine and administer. The client has developed a hypersensitivity reaction to metoclopramide resulting in dystonia (involuntarily movement of the limbs, face, head, neck and rapid blinking of eyes with spasms). The nurse should inform the prescriber of the dystonia and receive the antidote, diphenhydramine, and administer it. The hypersensitivity reaction could affect respiratory or swallowing, so it may become life threatening, if not treated promptly. The other actions may follow the first necessary action. Provide an environment to promote rest. Next, assess for pain relief, the therapeutic effect of ketorolac. Monitor for urinary retention, a potential adverse reaction of the anticholinergic action of metoclopramide.

A nurse is caring for a patient with chronic pain who has been prescribed epidural analgesia. The nurse should monitor the patient for which condition after insertion of the epidural catheter and throughout the therapy?

Respiratory depression The nurse should closely monitor the patient for respiratory depression after insertion of the epidural catheter and throughout the therapy. Patients using epidural analgesics for chronic pain are monitored for respiratory problems with an apnea monitor. The patient may also experience sedation, confusion, nausea, pruritus, or urinary retention. The nurse need not monitor the patient for abdominal pain, fever, and nervousness because they do not occur as a result of the administration of epidural analgesia.

An opioid antagonist will reverse which opioid effects? (Select all that apply.)

Respiratory depression Constipation Analgesia Hypotension Bradycardia Opioid antagonists are not selective for reversal of specific adverse reactions occurring with the use of an opioid, but will reverse all adverse reactions caused by opioids.

A nurse is caring for a client who required an opioid antagonist. Which should the nurse confirm to ensure that administration of the opioid antagonist is not contraindicated in the client?

The client is not hypersensitive to the opioid antagonist. The nurse should confirm that the client is not hypersensitive to the opioid antagonist to ensure that its administration is not contraindicated in the client. Elevated blood pressure is an adverse reaction of opioid antagonists, but administration of these drugs is not known to be contraindicated in clients with high blood pressure. Opioid antagonists are used cautiously in clients who are lactating and in clients who have cardiovascular disease, but presence of these conditions does not contraindicate the use of opioid antagonists.

While assessing clients receiving opioid analgesics for pain management, what finding would allert the nurse and require healthcare provider notification?

The client with a pulse of 118, a respiratory rate of 8, and a BP of 80/60 The primary healthcare provider should be contacted if the client's respiratory rate is 10 breaths per minute or less; and/or a significant increase or decrease in the client's pulse rate or quality is observed; and/or a significant decrease in blood pressure (systolic or diastolic) is observed; or a systolic pressure below 100 mm Hg is recorded.

Morphine, an opioid agonist, is administered for both acute and chronic pain. Along with the administered dosage, what determines the patient's response to morphine?

The route of administration Patient response to morphine depends on the route of administration and the dosage.

When evaluating the plan of care for a client receiving opioid analgesics for pain management, the nurse considers the plan successful when what occurs? (Select all that apply.)

Therapeutic response is achieved and discomfort is reduced. An adequate breathing pattern is maintained. Client maintains adequate nutritional status. The plan of care is considered effective when therapeutic response is achieved and discomfort is reduced; an adequate breathing pattern is maintained; the number of bowel movements is maintained; and adequate nutritional status is maintained. Urinary output should mirror increased fluid intake (increased fluid in, increased fluid out).

An elderly client experiencing recurrent tension headaches reports taking an over-the-counter (OTC) combination of acetaminophen, aspirin, and caffeine several times a week. The nurse should recognize that this combination medication may be contraindicated if the client has a history of what medical condition?

gastrointestinal (GI) bleeding Aspirin is normally contraindicated in clients who have had a history of GI bleeding. The other listed health problems do not contraindicate the use of combination acetaminophen, aspirin, and caffeine.

A nurse should not administer an opioid antagonist to a client with which finding?

hypersensitivity to naloxone The use of opioid antagonists is contraindicated in those with a hypersensitivity to the opioid antagonists; therefore, a client with a hypersensitivity to naloxone should not be given the drug. Naloxone can be given to uncontrolled type 2 diabetics. Having a history of opioid or alcohol abuse does not have any effect on the use of naloxone.

A 60-year-old client tearfully explains to the nurse how her husband downplays her frequent migraines and tells her that she needs to "just push through a headache." She describes how her migraines have limited her ability to provide childcare for her young grandchildren and explains that she is unable to keep up her garden. The nurse should identify what nursing diagnosis when planning this client's care?

ineffective role performance related to migraine headaches Many nursing diagnoses likely apply to this client's situation, but there is evidence that she grieves her inability to perform a caregiving role for her grandchildren. There is no evidence that the client's health maintenance is inadequate or that she has low self-esteem. Spiritual distress is also not in evidence.

A client has been administered an opioid. What effect should the client be regularly assessed for?

level of consciousness (LOC) Opioids will produce decreased LOC. Oliguria is not a result of the administration of an opioid. Edema is not a result of the administration of an opioid. Tachycardia is not a result of the administration of an opioid.

A middle-aged client describes her headaches as "utterly debilitating" and tells the nurse, "It's hard to explain, but I just know when one is coming, and I'm never wrong." This client's statement suggests what diagnosis?

migraines The severity of her headaches coupled with the fact that she experiences a prodrome suggests that she experiences migraines. This clinical presentation is not typical of cluster headaches or tension headaches. Ischemic headache is not a recognized subtype.