A client has been taking oxycodone for pain. The client has returned three times for refills of the prescription. In addition to slurred speech, which assessment leads the nurse to suspect opioid Intoxication?

Lability of mood

Hypervigilance

Constricted pupils

Increased respirations

Answer and Explanation

The Correct Answer is C

C. Constricted pupils, also known as miosis, are a classic sign of opioid intoxication. Opioids act on opioid receptors in the brainstem, which can lead to pupillary constriction.
A. Lability of mood refers to rapid and unpredictable changes in mood, which is not a typical finding in opioid intoxication.
B. Hypervigilance is not typically associated with opioid intoxication. Instead, opioid intoxication tends to cause CNS depression, leading to symptoms such as drowsiness, sedation, and impaired consciousness.
D. Opioid intoxication typically causes respiratory depression rather than increased respirations. Opioids depress the central respiratory drive, leading to shallow, slow, or irregular breathing patterns.

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Correct Answer is C

Explanation

C. Bringing birth certificates and Social Security cards is essential for establishing identity and accessing necessary services, such as shelters, legal assistance, or government benefits. These documents may be needed for applying for assistance, obtaining housing, or enrolling children in school.
A. Ensuring the well-being and comfort of any children involved is important but bringing toys to amuse them for a few days may not be the highest priority when creating an escape plan from spousal abuse.
B. A cell phone can be used to call for help, contact emergency services, or reach out to trusted individuals for assistance. However, it is not the most important item.
D. Having reading materials may provide distraction and comfort during stressful times but they are not typically considered essential items for an escape plan from spousal abuse.

A. Assess for past history of suicide attempts. B. Determine whether the client has a specific plan to commit suicide. C. Identify coping mechanisms. D. Notify all members of the treatment team and place the client on suicide precautions.

Correct Answer is D

Explanation

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

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A client has been taking oxycodone for pain. The client has returned three times for refills of the prescription. In addition to slurred speech, which assessment leads the nurse to suspect opioid Intoxication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. The nurse would recommend that the victim bring:

Correct Answer is C

Explanation

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Correct Answer is D

Explanation

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