can't find the prioritization answer - page 4

by Helenz

Q: you have give Morphine sulfate 4mg IV to a client who has an acute MI. when you evaluate the client's response 5 mins after giving the medication, which of these indicates a need for immediate further actions? A: 1. the... Read More


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    Quote from Helenz
    Q:
    you have give Morphine sulfate 4mg IV to a client who has an acute MI. when you evaluate the client's response 5 mins after giving the medication, which of these indicates a need for immediate further actions?

    A:
    1. the blood pressure decreases from 114/65 to 106/58 mm Hg.
    2. the respiratory rate drop from 18 to 12 breaths/min.
    3. the cardiac monitor indicates sinus rhythm at a rate of 96 beats/min.
    4. the client still has chest pain at level of 1(on a scale of 0 to 10)

    anyone who can help me find the right answer? and why ?
    Well......
    1. The B/P drop 5 min after administering Morphine....is not a significant drop.
    2. The resp rate drop when this is five min after IV Morphine, while it bears watching, the resp rate is still within normal limits.
    3. The cardiac monitor tells me that the patient has a normal is not slightly rapid heart rate after MS04 administration indicating some distress.
    4. The patient continues to have pain indication that further interventions will be necessary.

    Number 4.
    Helenz likes this.
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    thank you for all you help, the right answer is #4.

    answer key from book: [COLOR=#000000]Goal in pain management for the client with an acute MI is to completely eliminate the pain.Even pain rated at a level of 1 out of 10,should be treated with additional morphine(possibly lower dose).the other date indicate a need for ongoing assessment for the possible adverse effects of hypertension respiratory depression, and tachycardia but do not require further action at this time.[/COLOR]
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    In terms of action, it would have to be 4 as the other instances "only" require monitoring (for now) not "action."

    However, I disagree with the "goal" the all pain needs to be completely. A person can live with 1/10 pain...the cannot live with significant heart muscle death. The real action that every needs to work for is reperfusion therapy, and ten does of morphine is not going to accomplish that goal.
    Last edit by psu_213 on Nov 18, '12
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    Quote from psu_213
    In terms of action, it would have to be 4 as the other instances "only" require monitoring (for now) not "action."

    However, I disagree with the "goal" the all pain needs to be completely. A person can live with 1/10 pain...the cannot live with significant heart muscle death. The real action that every needs to work for is reperfusion therapy, and ten does of morphine is not going to accomplish that goal.
    I agree, I can see the rational behind answer 4 but would never pick that answer on a test. I think a pt breathing is more important than taking away all pain. We could easily kill this person by trying to make their pain 0. The pt's tissue may have already been compromised and I would think the goal is to perfuse tissue, control pain and anxiety (decreases work load of heart and a level 1 of pain would do this), and prevent further muscle damage.
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    Quote from mariebailey
    Ahh...I meant to say it is #4.
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    id choose #2 think about ABC respiratory rate is dropping 18 down to 12 per min its alarming
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    The question asked for "immediate" action for response. I would select #2 because my immediate response to 12 breaths/minute is to encourage deep breathing. If the patient "still" has a pain rate of 1. I don't think you would immediately give more Morphine to make his pain rate 0. The goal is to promote perfusion to the heart and decrease further ischemia ( which is causing the chest pain).
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    Quote from OrNurrse03
    The question asked for "immediate" action for response. I would select #2 because my immediate response to 12 breaths/minute is to encourage deep breathing. If the patient "still" has a pain rate of 1. I don't think you would immediately give more Morphine to make his pain rate 0. The goal is to promote perfusion to the heart and decrease further ischemia ( which is causing the chest pain).
    I like your though of the action of encouraging deep breathing. On the other hand, option 4 does not say that your action has to be give more morphine. The question is only asking which piece of assessment data requires action. The action could be to give NTG.
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    Quote from gatoraimsLPN
    I agree, I can see the rational behind answer 4 but would never pick that answer on a test.
    For a test, 4 would be correct. In the real world I would be much less concerned about 1/10 pain than I would be about reparatory depression...oh, sorry, how can I possibly make a connection between NCLEX questions and the real world? We all know that the former does not reflect the latter.


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