Pharm 2 CH 26
A client who has been prescribed sumatriptan as abortive therapy for migraines reports, "I took that pill about an hour-and-a-half ago, but I feel like a headache is returning. Can I take another pill?" How should the nurse respond? "Wait at least half-an-hour before you take another pill." "Yes, it's likely safe to take one more dose of your sumatriptan." "You should probably go to the emergency department." "You can take another pill now and one more in 1 hour, but then no more."
"Wait at least half-an-hour before you take another pill." Explanation: Clients can take a second dose of oral sumatriptan when symptoms return but no sooner than 2 hours after the first tablet. There's no evidence that the client needs to go to the emergency department.
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 10 to 15 minutes 15 to 30 minutes 30 to 60 minutes
1 to 2 minutes Explanation: 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 09:30. What time should the nurse reassess the client for peak analgesic effect? 9:45 10:00 10:30 11:00
10:30 Explanation: With oral administration, peak activity occurs in about 60 minutes. The duration of action is 5 to 7 hours.
The nurse administers an oral dose of morphine to a client at 3:00 PM. The nurse would expect the drug to peak at which time? 3:30 PM 4:00 PM 4:30 PM 5:00 PM
4:00 PM Explanation: Oral morphine peaks in approximately 1 hour; in this situation, it would be 4:00 PM.
The nurse knows that, of the following clients, who is least likely to be prescribed transdermal fentanyl? A woman 85 years of age A man 25 years of age A man 50 years of age A woman 35 years of age
A woman 85 years of age Explanation: 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.
The nurse is planning care for the client who has been admitted to the emergency department with an acute migraine headache. What is the most appropriate nursing diagnosis for this client? Fluid volume excess Acute pain Activity intolerance related to muscle pain Fear related to migraine headache
Acute pain Explanation: The most appropriate nursing diagnosis for this client is acute pain. There is no indication that the client has fluid volume excess or activity intolerance related to muscle pain or that the client is full of fear.
The nurse suspects opioid overdose in a client after surgery. What interventions must the nurse initiate for this client? (Select all that apply.) Administer naloxone Decrease the client's IV fluids Notify the health care provider Prepare for endotracheal intubation Insert a Foley catheter
Administer naloxone Notify the health care provider Prepare for endotracheal intubation Explanation: The nurse will notify the provider, administer naloxone, and prepare for endotracheal intubation. If the client has an IV, the nurse would increase the rate. It is possible the nurse would insert a Foley catheter, but it is not a priority nursing intervention at this time. The priority interventions revolve around the client's respiratory status.
The client is having surgery this week. What information should the nurse give the client concerning the use of pain medication after surgery? Take as little pain medication as possible to prevent addiction. Ask for pain medication before the pain gets severe. Request your pain medication whenever it is available to you. Wait as long as possible for pain medication; it will work more effectively.
Ask for pain medication before the pain gets severe. Explanation: 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.
The nurse is caring for a postoperative client taking an opioid medication for pain. The nurse assesses the client to have bradypnea 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. Call for a respiratory therapy consult. Reassess the client's level of pain. Reposition the client for comfort.
Assess the client's other vital signs. Explanation: 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 observes that a new client's medication regimen includes sumatriptan. What assessment should the nurse prioritize? Assessing the client for migraine pain Assessing the client for narcotic withdrawal syndrome Assessing the client for respiratory depression Assessing the client's lying, sitting and standing blood pressure
Assessing the client for migraine pain Explanation: 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.
To decrease the risk of injury to a client taking an opioid, what should the nurse do? (Select all that apply.) Keep the lights in the client's room turned down. Assist client from their bed to the toilet. Assist client with rising from a lying position. Assist client with hall-walking activities. Advise the client to stay in bed all night.
Assist client from their bed to the toilet. Assist client with rising from a lying position. Assist client with hall-walking activities. Explanation: To decrease the risk of injury to a client taking an opioid, the nurse should assist the client with ambulatory activities and with rising from a sitting or lying position. The nurse should also keep the client's room well-lit during daytime hours, keep the client's room free of clutter, and advise the client to seek assistance when getting out of bed at night.
The nurse has administered a dose of naloxone and the client's respiratory depression improved within five minutes. When the nurse reassessed the client two hours later, the client demonstrates symptoms of respiratory depression. Which action should the nurse perform next? No further action is required because the naloxone has already been administered. Call the provider as another dose of opioid antagonist may be necessary. Administer a second dose and then notify the provider to obtain an order. Continue to monitor the client's vital signs and oxygen saturation levels.
Call the provider as another dose of opioid antagonist may be necessary. Explanation: The effects of some opioids may last longer than the effects of naloxone. A repeat dose of naloxone may be ordered if results obtained from the initial dose are unsatisfactory. Therefore, calling for an order would be an appropriate response. Taking no action in light of respiratory depression, or merely continuing to monitor the client, could lead to deterioration in the client's condition. No medication should be administered without a provider order.
A nurse is teaching a client about the prescription for acetaminophen to be taken at home. This medication consists of acetaminophen and what other likely drug that enhances the analgesic effect of acetaminophen? Codeine Acetylsalicylic acid Methadone Tramadol
Codeine Explanation: Codeine is often given with acetaminophen for additive analgesic effects. None of the other medications are used in combination with acetaminophen.
A nurse is caring for a client with renal impairment. The client has been prescribed an opioid analgesic. Which nursing intervention would be most appropriate? Provide aggressive bowel program. Administer the drug through the IV route. Consult with the prescriber about lowering the dosage of the drug. Administer an antacid with the drug.
Consult with the prescriber about lowering the dosage of the drug. Explanation: The nurse should lower the dosage of the drug when caring for a client with renal impairment who has been prescribed an opioid analgesic, but only after consulting with the prescriber and obtaining a prescription to do so. The nurse has to provide an aggressive bowel program to clients who experience an adverse reaction on their GI system due to the action of the opioid analgesics. Use of an antacid is recommended only if prescribed by the primary health care provider under specific circumstances. The nurse need not administer the drug through the IV route for a client with renal impairment who has been prescribed opioid analgesics.
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? Antibiotic Antihypertensive Monoamine oxidase (MAO) inhibitor NSAID
Monoamine oxidase (MAO) inhibitor Explanation: The client should not receive morphine within 14 days of receiving an MOA inhibitor.
The health care provider is preparing a prescription for sumatriptan for a client diagnosed with migraine headaches. What information in the client history would contraindicate this medication? Allergy to NSAIDs Renal impairment History of myocardial infarction Connective tissue disorder
History of myocardial infarction Explanation: Because of their vasoconstrictive properties, triptans are contraindicated in clients with a history of angina pectoris, myocardial infarction, or uncontrolled hypertension. Caution is required in clients with renal impairment, but the condition is not an outright contraindication. Connective tissue disorder and allergy to NSAIDs are not contraindications.
The nurse notes a respiratory rate of 6 breaths/min in a client in the postanesthesia recovery unit. Which drug would the nurse anticipate being given immediately? Acetaminophen and diphenhydramine Epinephrine Butorphanol Naloxone
Naloxone Explanation: Naloxone 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. Butorphanol would worsen respiratory depression. Acetaminophen and diphenhydramine are used to treat headache. Epinephrine may be prescribed for an allergic reaction but not for respiratory depression.
The pathophysiology of pain begins with a signal from what source? Myelin sheaths Nociceptors Baroreceptors Synapses
Nociceptors Explanation: For a person to feel pain, the signal from nociceptors in peripheral tissues must be transmitted to the spinal cord, then to the hypothalamus and cerebral cortex in the brain. Myelin sheaths, synapses, and baroreceptors are not directly involved in pain transmission.
What would the nurse expect to assess in a client receiving a narcotic for pain relief? Dilation of the pupils Diarrhea Orthostatic hypotension Tachypnea
Orthostatic hypotension Explanation: Narcotics are associated with orthostatic hypotension, pupil constriction, constipation, and respiratory depression with apnea.
What factors affect how the patient will experience and respond to pain? Select all that apply. Past experience with pain Cultural expectation about how one should respond to pain Learned behavior from childhood It is a conscious response that the patient has a choice about.
Past experience with pain Cultural expectation about how one should respond to pain Learned behavior from childhood Explanation: The experience of pain is personal and subjective; however, how people respond to painful stimuli reflects what they have learned about pain from their families, society, and cultures of origin. Learned messages about pain are indirect, and people react to them subconsciously. These messages include reasons that people experience pain and what are considered appropriate responses to it.
A nurse should recognize which situations necessitate the need for an opioid antagonist. Which situations necessitate the need for an opioid antagonist? (Select all that apply.) Postoperative acute respiratory depression Reversal of phenytoin toxicity Reversal of opioid induced hypotension Suspected acute benzodiazepine overdosage Suspected acute opioid overdosage
Postoperative acute respiratory depression Reversal of opioid induced hypotension Suspected acute opioid overdosage Explanation: Opioid antagonists are used for the treatment of the following: postoperative acute respiratory depression, reversal of opioid adverse effects (hypotension, bradycardia, etc.), and suspected acute opioid overdosage.
The nurse is to administer an opioid antagonist. The nurse knows that the valid reasons for administering this type of medication include what reasons? (Select all that apply.) Postoperative acute respiratory depression Reduction of acute postoperative surgical site pain Suspected or known acute opioid overdosage Adverse effects related to opioid administration Enhancement of an opioid analgesic physiologic effect
Postoperative acute respiratory depression Suspected or known acute opioid overdosage Adverse effects related to opioid administration Explanation: Opioid antagonists are used for the treatment of acute respiratory depression, overdosage, and adverse effects of opioid administration. Administration often counters the pain-relieving effects of an opioid medication and does not enhance opioid effects. These are not actions of an opioid antagonist.
Which assessment finding would support a client's report of migraine headaches? Severe unilateral pulsating pain Sharp steady eye pain Dull band of pain around the head Onset occurring during sleep
Severe unilateral pulsating pain Explanation: 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.
The nurse reviews a client's medication administration record before giving a new medication. For which medication would the nurse question giving the client a dose of tapentadol? metformin vitamin D3 St. John's wort vitamin B complex
St. John's wort Explanation: Tapentadol is an opioid agonist used to relieve moderate to severe neuropathic pain. There is a risk of serotonin syndrome if it is combined with St. John's wort. Tapentadol can be safely taken with metformin and other vitamin supplements such as vitamin D3 and vitamin B complex.
Which adverse reactions may occur as a result of administering an opioid antagonist? Diarrhea, cramping, and increased pain rating Decreased blood pressure and decreased pulse Increased temperature and decreased oxygen saturation Sweating, tachycardia, and increased blood pressure
Sweating, tachycardia, and increased blood pressure Explanation: Side effects of opioid antagonists include nausea and vomiting, sweating, increased blood pressure, and tremors. All other side effects listed are not side effects of opioid antagonists.
A client diagnosed with migraines expresses interest in taking an over-the-counter acetaminophen, aspirin, and caffeine combination drug. Which information presented in the client's history should prompt the nurse to discourage the client from taking the drug? The client has not adhered to previous treatment regimens. The client has a chronic venous ulcer on the lower leg. The client has a diagnosis of liver cirrhosis. The client is a smoker.
The client has a diagnosis of liver cirrhosis. Explanation: 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.
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 lactating. The client does not have high blood pressure. The client is not hypersensitive to the opioid antagonist. The client does not have a cardiovascular disease.
The client is not hypersensitive to the opioid antagonist. Explanation: 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.
The nurse is caring for a postoperative client with a history of opioid abuse who has been ordered to receive a dose of an opioid antagonist medication. Which issues should the nurse be prepared to address? During pain assessment, the client may report less pain. The client may begin to demonstrate symptoms of withdrawal. Double the standard dosage of the medication may be needed. Multiple doses may be needed to be therapeutic.
The client may begin to demonstrate symptoms of withdrawal. Explanation: The client may begin to demonstrate symptoms of withdrawal when he or she has a history of opioid abuse and is administered an opioid antagonist. The other answers are incorrect. In fact, clients will likely have increased pain due to antagonistic effects of the drug. The standard dosage and a single dose will be administered even with a history of opioid abuse.
An adult client with a history of migraines has been prescribed propranolol. The nurse should identify what goal of therapy when planning care for a client prescribed propranolol? The client will experience significantly fewer migraines. The client's migraines will be shorter in duration than prior to treatment. The client's migraines will be lower in intensity than prior to treatment. The client will be able to perform activities of daily living during migraines.
The client will experience significantly fewer migraines. Explanation: Propranolol is used for the prevention of migraines. As such, the primary goals are not reduced duration or intensity of migraines. In addition, the nurse would not identify the goal of continuing normal routines during a migraine.
The nurse administers hydromorphone IV to the postoperative client as prescribed. What is the best method for the nurse to evaluate the client's response to the medication? Observe the client's behavior without the client's awareness, 30 minutes after administration. Use a pain assessment tool before and 30 minutes after administration. Assess the client's vital signs before and after drug administration. Ask the client if the medication has been effective.
Use a pain assessment tool before and 30 minutes after administration. Explanation: A standard pain assessment tool should be used both pre- and postanalgesia. This type of data is more accurate than asking the client a yes/no question about the effectiveness of the medication. The nurse should observe the client's response, but this does not provide the most accurate assessment data. Similarly, vital signs should be monitored, but trends do not necessarily demonstrate effectiveness.
A group of students is reviewing various methods for assessing pain. The students demonstrate understanding of the material when they identify what as the most reliable method? Using a pain rating scale Asking a client to describe his or her pain Percussing or palpating the area where pain is identified Assessing the client's vital signs
Using a pain rating scale Explanation: A pain rating scale is the most reliable method because it provides measurable evidence of pain severity. A client's description of pain is useful, but does not provide objective or quantifiable data over time. Although percussing or palpating provides information, it would increase the client's pain and be inappropriate. Vital sign changes occur for numerous reasons and are not the best indicator of pain in clients who can speak.
The nursing instructor is talking with the junior nursing class about migraine headaches. What would the instructor tell the students is the method of action of sumatriptan? Vasoconstrictive on cranial blood vessels Causes vasodilation of cranial blood vessels Dulls the perception of pain in the brain Helps prevent onset of migraine headache
Vasoconstrictive on cranial blood vessels Explanation: Sumatriptan binds to serotonin receptors to cause vasoconstrictive effects on cranial blood vessels, which is the cause of migraine headaches. The goal is to do more than just dull the pain. Sumatriptan cannot be given to help prevent migraine headaches. .
A health care provider suggests opioid treatment for a client with respiratory depression. The nurse should be aware of which condition that can occur during an abrupt reversal of opioid respiratory treatment? Dizziness Headache Vomiting Light-headedness
Vomiting Explanation: The nurse should know that an abrupt reversal of opioid respiratory treatment results in vomiting. The nurse must maintain a patent airway and should turn and suction the client as needed in such cases. Headache, dizziness, and light-headedness are not known to occur during an abrupt reversal of opioid respiratory treatment.
The nurse receives a prescription for morphine sulfate 8 mg IV every hour as needed for pain. For what client should the nurse question this order? a 78-year-old client with osteoarthritis a 45-year-old client, 1-day postoperative mastectomy a 28-year-old client with a fractured tibia a 17-year-old client, 1-day postoperative appendectomy
a 78-year-old client with osteoarthritis Explanation: Older clients are more likely to experience the adverse effects associated with narcotics, including central nervous system, gastrointestinal, and cardiovascular effects. Furthermore, a strong narcotic analgesic would not be indicated for chronic osteoarthritis pain. For both of these reasons, the nurse would question the large dosage of a narcotic. The other clients could appropriately receive morphine 8 mg unless they were smaller than average adults.
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. management of alcohol withdrawal symptoms. a reduction in the client's rating of their pain. alertness and improve memory function.
a return to normal respiratory rate, rhythm, and depth. Explanation: 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 nurse would expect to administer an opioid agonist as the analgesic of choice for which patients? a. A patient with severe postoperative pain b. A patient with severe chronic obstructive pulmonary disease and difficulty in breathing c. A patient with severe, chronic pain d. A patient with ulcerative colitis e. A patient with recent biliary surgery f. A patient with cancer and severe bone pain
a. A patient with severe postoperative pain c. A patient with severe, chronic pain f. A patient with cancer and severe bone pain
A postsurgical client has been receiving morphine by patient-controlled analgesic for 2 days. What action by the nurse best addresses potential adverse effects? administering a stool softener as prescribed auscultating the client's lung for adventitious sounds encouraging active range of motion exercises applying calf compressors as prescribed
administering a stool softener as prescribed Explanation: Narcotics create a significant risk for constipation, and relevant nursing interventions are required. Respiratory rate must be closely monitored, but there is not a high likelihood of adventitious lung sounds. There is no obvious risk for venous stasis that would require calf compressors. Exercises have general benefits but do not address the particular adverse effects of morphine.
A postsurgical client has been prescribed morphine to address the pain that is anticipated over the next 24 to 48 hours. What is the most effective strategy to manage a client's postsurgical pain for the initial 24 to 48 hours? administering the maximum safe dose of morphine for 12 to 24 hours and then transitioning to nonsteroidal anti-inflammatory drugs (NSAIDs) administering morphine on a scheduled basis and supplementing it with additional morphine when the pain worsens administering morphine every 4 hours, with gradually decreasing doses over the next several days encouraging the client to endure the pain as much as possible before administering morphine
administering morphine on a scheduled basis and supplementing it with additional morphine when the pain worsens Explanation: In general, morphine should be given continuously or on a regular schedule of intermittent doses, with supplemental or bolus doses when needed for breakthrough pain. None of the other options provide accurate information about the management of postsurgical pain.
Which of the following is correct about pain according to the gate control theory? a. It is caused by gates in the CNS. b. It can be blocked or intensified by gates in the CNS. c. It is caused by gates in peripheral nerve sensors. d. It cannot be affected by learned experiences.
b. It can be blocked or intensified by gates in the CNS.
Opioid agonists are drugs that react with opioid receptors throughout the body. Which conditions would the nurse expect to find when assessing a patient who was taking an opioid agonist? a. Hypnosis b. Sedation c. Analgesia d. Euphoria e. Orthostatic hypotension f. Increased salivation
b. Sedation c. Analgesia d. Euphoria e. Orthostatic hypotension
The triptans are a class of drugs that bind to serotonin receptor sites and cause a. cranial vascular dilation. b. cranial vascular constriction. c. clinical depression. d. nausea and vomiting.
b. cranial vascular constriction.
Proper administration of an ordered opioid a. will frequently lead to addiction. b. should be done promptly to prevent increased pain and the need for larger doses. c. would include holding the drug as long as possible until the patient really needs it. d. should rely on the patient's request for medication.
b. should be done promptly to prevent increased pain and the need for larger doses.
Injecting an opioid into an area of the body that is chilled can be dangerous because a. an abscess will form. b. the injection will be very painful. c. an excessive amount may be absorbed all at once. d. narcotics are inactivated in cold temperatures.
c. an excessive amount may be absorbed all at once.
Opioid agonists are controlled substances because they a. are very expensive. b. can cause respiratory depression. c. can cause physical dependency and addiction. d. can be used only in a hospital setting.
c. can cause physical dependency and addiction.
The only triptan that has been approved for use in treating cluster headaches as well as migraines is a. naratriptan. b. rizatriptan. c. sumatriptan. d. zolmitriptan.
c. sumatriptan.
Opioid receptors are found throughout the body a. only in people who have become addicted to opiates. b. in increasing numbers with chronic pain conditions. c. to incorporate pain perception and blocking. d. to initiate the release of endorphins.
c. to incorporate pain perception and blocking.
Migraine headaches a. occur during sleep and involve sweating and eye pain. b. occur with stress and feel like a dull band around the entire head. c. often occur when drinking coffee. d. are throbbing headaches on one side of the head.
d. are throbbing headaches on one side of the head.
A 30-year-old client experiences migraines that appear closely linked to her menstrual cycle. What pharmacologic treatment is most specific to this client's particular experience of migraines? estradiol ergotamine almotriptan chlorpromazine
estradiol Explanation: Estrogen in the form of estradiol is a treatment specific to menstrual migraines, which are most likely 2 days prior to menses through the third of bleeding. Adjuvants (such as chlorpromazine) and other abortive treatments (such as ergotamine and almotriptan) may be indicated, but these are not specific to menstrual migraines.
A nurse should not administer an opioid antagonist to a client with which finding? hypersensitivity to naloxone uncontrolled type 2 diabetes history of opioid abuse history of alcohol abuse
hypersensitivity to naloxone Explanation: 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.
The nurse is caring for a client whose pain is being treated with pentazocine. What would be an appropriate nursing diagnosis for this client's care plan? diarrhea related to adverse gastrointestinal effects risk for autonomic dysreflexia related to central nervous system depression risk for infection related to immune system depression impaired gas exchange related to respiratory depression
impaired gas exchange related to respiratory depression Explanation: Nursing diagnoses may include impaired gas exchange related to respiratory depression. The drug is more likely to cause constipation due to slowing of the GI tract instead of diarrhea. The drug has no effect on immune function. Autonomic dysreflexia is not caused by CNS depression and is limited to clients with spinal cord injuries.
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 health maintenance related to migraine headaches ineffective role performance related to migraine headaches situational low self-esteem related to migraine headaches spiritual distress related to migraine headaches
ineffective role performance related to migraine headaches Explanation: 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.
The nurse is caring for a client who is receiving morphine via patient-controlled analgesia (PCA). In addition to pain assessment, what assessments should the nurse prioritize? apical heart rate and temperature level of consciousness and respiratory rate respiratory rate and fluid balance urine output and inspection of the IV site
level of consciousness and respiratory rate Explanation: The nurse should assess respiratory rate and level of consciousness because respiratory depression and sedation are adverse effects of opioid analgesics. None o
A nurse has just administered an IM injection of meperidine (Demerol) to an elderly client. The priority nursing action for the nurse would be which? close the draperies. make sure the side rails are up. check the temperature of the room. make sure the client is positioned comfortably.
make sure the side rails are up. Explanation: The priority nursing action will be to make sure that the side rails are up. Meperidine can cause dizziness and sedation, which increase the risk of the client falling. The side rails should be up to remind the client that she should not get out of bed without help. Closing the draperies, checking the temperature of the room, and making sure the client is comfortable creates an environment that will enhance the efficacy of the medication therapy but are not the priority actions.
The nurse is assessing a new client whose medication regimen includes estradiol, which the client states that she is taking for the treatment of migraines. The nurse should recognize the need to assess what? menstrual cycles psychosocial stressors respiratory system integumentary system
menstrual cycles Explanation: Estrogen in the form of estradiol is a treatment for menstrual migraines, which are most likely 2 days prior to menses through the 3rd day of bleeding. Because of the likelihood of this etiology, it is appropriate for the nurse to discuss the client's menstrual cycles with her. Adverse effects do not normally involve the integumentary or respiratory systems. The etiology of the client's migraines more likely involves physiology than psychosocial factors, so the nurse should assess accordingly.
Opioid antagonists may produce withdrawal symptoms in clients physically dependent on which substance? opioids alcohol NSAIDs benzodiazepines
opioids Explanation: Opioid antagonists may produce withdrawal symptoms in clients physically dependent on opioids. Naloxone has no effect on benzodiazepines, alcohol, or NSAIDs.
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? renal impairment. myocardial infarction. hypersensitivity to the drug. pneumonia.
pneumonia. Explanation: 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.
Acetaminophen-aspirin-caffeine act on a migraine headache by: reducing pain associated with a migraine. using inflammation to decrease the migraine pain. triggering vasodilation of the coronary blood vessels. preventing the frequency of migraine attacks.
reducing pain associated with a migraine. Explanation: The action of acetaminophen-aspirin-caffeine decreases pain. Acetaminophen acts as an analgesia. Aspirin works as an anti-inflammatory. Caffeine causes constriction of the cerebral blood vessels and not vasodilation of the coronary blood vessels. The medication is not used in prevention of migraines.
Morphine has been prescribed for a 28-year-old man with severe pain due to a back injury. The nurse is teaching the client upon discharge to avoid alcohol while taking this medication because it can cause which? respiratory depression over stimulation of the back muscles kidney pain urinary retention
respiratory depression Explanation: The nurse should advise the client to avoid alcohol and any other CNS depressants while taking morphine. These combinations can cause serious respiratory depression and sedation. Over stimulation of back muscles, kidney pain and urinary retention are not know effects of this interaction.
An 80-year-old man has been prescribed oxycodone for severe, noncancer, chronic pain. He tells the nurse that he has difficulty swallowing and asks if he can crush the tablet before swallowing. The nurse will advise the client that: the tablet would have no effect if crushed and ingested. there is risk of an extremely high dose available all at once if the tablet is crushed. crushing the tablet increases the drug's efficacy. crushing the tablet is a safe option.
there is risk of an extremely high dose available all at once if the tablet is crushed. Explanation: The nurse should caution the client against crushing the tablet before ingesting it. Crushing allows an extremely high dose of the drug to be available all at once, instead of being released slowly over time. Severe adverse effects are possible when it is used in this manner.
A client with a history of migraines has been prescribed sumatriptan and is experiencing relief. What physiologic response is the client most likely experiencing? vasoconstriction of cranial blood vessels increased synthesis and release of endorphins stimulation of A-delta stimulation of C fibers
vasoconstriction of cranial blood vessels Explanation: Sumatriptan binds to serotonin receptors to cause vasoconstrictive effects on cranial blood vessels. It does not directly influence endorphin levels. Stimulation of A-delta and C fibers causes increased, not decreased, pain levels.
