Patient Data The charge nurse places a fall precautions sign on the client's door. Which side effects of morphine could contribute to this client's fall risk? Select all that apply
Explanation & Rationale
A. Nausea: Morphine commonly causes nausea, which can lead to dizziness and unsteadiness when standing or moving. This increases the client’s risk of falls, especially when transitioning from bed to chair or ambulating postoperatively. B. Euphoria: While morphine may cause a sensation of euphoria, this emotional effect alone does not directly contribute to physical instability or fall risk in the immediate postoperative period. C. Itching: Itching is a common side effect of opioids but does not impair balance or mobility directly, so it is not a significant contributor to fall risk. D. Orthostatic hypotension: Morphine can cause vasodilation, leading to drops in blood pressure when moving from lying to sitting or standing. Orthostatic hypotension can result in lightheadedness or fainting, sharply increasing the risk of falls. E. Seizures: Seizures are rare side effects of morphine, typically associated with very high doses or toxicity. They are not in standard therapeutic use to be considered a primary fall risk factor. F. Urinary retention: Urinary retention is a side effect of morphine but does not directly cause instability or contribute to falls unless it leads to urgency and hurried movement, which is less typical. G. Sedation: Sedation is one of the most significant opioid side effects contributing to falls. Reduced alertness and slower reflexes make it much harder for clients to safely ambulate or protect themselves from falls.