a nurse is assessing a client who is receiving morphine via a patient controlled analgesia pca pump which of the following findings should the nurse i a nurse is assessing a client who is receiving morphine via a patient controlled analgesia pca pump which of the following findings should the nurse i
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ATI Exit Exam 2023 Quizlet

1. A healthcare professional is assessing a client receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the healthcare professional identify as an adverse effect of the medication?

Correct answer: C

Rationale: Hypotension is a common adverse effect of morphine due to its vasodilatory properties. It can lead to a drop in blood pressure, which should be closely monitored during administration. Diarrhea (Choice A) is not a typical adverse effect of morphine. Urinary retention (Choice B) is a side effect of morphine due to its impact on the bladder muscles, but it is not classified as an adverse effect. Bradycardia (Choice D) is not a common adverse effect of morphine; instead, it tends to cause tachycardia.

2. Which of the following structures, located at the end of the ear canal, vibrates when sound waves strike it?

Correct answer: Tympanic membrane

Rationale: The correct answer is the Tympanic membrane. The tympanic membrane, also known as the eardrum, is located at the end of the ear canal and vibrates when sound waves strike it. This vibration is then transmitted to the ossicles in the middle ear, which amplify and transmit the sound to the inner ear. Choice A, the Acoustic meatus, is incorrect as it is the ear canal itself, not the structure that vibrates. Choice B, the Cochlea, is responsible for translating sound vibrations into electrical signals but is not located at the end of the ear canal. Choice C, the Eustachian tube, is responsible for equalizing pressure between the middle ear and the atmosphere and is not involved in vibration from sound waves.

3. Which of the following foods provides the most protein?

Correct answer: A

Rationale: The correct answer is 'Beans.' Beans are a rich source of plant-based protein, making them the best option among the listed foods for protein content. Red peppers, asparagus, and celery are not significant sources of protein compared to beans, hence they are incorrect choices for this question.

4. A nurse is providing client education regarding lithium therapy. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B. The nurse should instruct the client to avoid excessive intake of caffeinated beverages as they can interfere with lithium levels. Option A is incorrect as lithium is usually recommended to be taken on an empty stomach. Option C is not directly related to lithium therapy. Option D is not a typical instruction for lithium therapy.

5. A 25-year-old woman who works as an air traffic controller presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at the airport. What is the most likely diagnosis?

Correct answer: C

Rationale: The most likely diagnosis for the 25-year-old woman who works as an air traffic controller and presents with facial pain and severe headache that sometimes radiates to her neck or ear, aggravated by stress, is Temporomandibular joint syndrome. This syndrome involves pain in the jaw joint and the muscles controlling jaw movement, which can radiate to the surrounding areas like the neck and ear. Stress and clenching of the jaw commonly exacerbate the symptoms. Migraine headache (choice A) typically presents with other symptoms like nausea, sensitivity to light or sound, and can be triggered by various factors, not just stress. Cluster headache (choice B) is characterized by severe, unilateral pain around the eye with associated autonomic symptoms. Sinus headache (choice D) is usually associated with sinus congestion or infection, presenting with facial pressure or pain, often worsened by bending forward.

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