A nurse in a community clinic is assessing a client who reports injecting heroin 1 hr ago. Which of the following findings should the nurse expect?
Dilated pupils
Tachypnea
Euphoria
Nystagmus
The Correct Answer is A
Explanation: Heroin is a central nervous system depressant that can cause various physiological effects on the body. Dilated pupils are a common sign of heroin use, along with a decrease in blood pressure, respiratory rate, and heart rate. The pupils will appear larger than usual because heroin depresses the parasympathetic nervous system, which controls the size of the pupils.
Tachypnea, or rapid breathing, is not typically associated with heroin use, as it is a central nervous system depressant. Euphoria, or a feeling of intense pleasure or happiness, is a common effect of heroin use, but it is not the most reliable sign of heroin use, as other drugs can also produce this effect. Nystagmus, an involuntary movement of the eyes, is not a common sign of heroin use. Dilated pupils are a reliable sign of heroin use and should be documented in the client's medical record. It is important for the nurse to assess for other signs of drug use and to provide appropriate care and support to the client, which may include referrals for substance abuse treatment. The nurse should also follow agency policies and procedures for reporting drug use and abuse to appropriate authorities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, "Describe the place where you are currently living." When discussing discharge plans with a client, the first step is to assess the client's living situation to ensure that they will be able to safely manage their health condition at home. In this case, the client requires a special bed at home due to their pressure injury. By asking the client to describe their living situation, the case manager can determine if the client's home is suitable for their needs or if they require additional assistance or resources. Once the client's living situation has been assessed, the case manager can then discuss options for obtaining necessary supplies and provide education on how to manage the pressure injury.
Correct Answer is ["B","C","D"]
Explanation
The correct answers are B, C, and D. The nurse should assist the client in using guided imagery, maintain the head of the client's bed in an elevated position after eating, and provide sips of room-temperature ginger ale between meals. Guided imagery can help distract the client from the nausea and promote relaxation.
Elevating the head of the bed after eating can help prevent reflux and nausea. Ginger ale can help relieve nausea and can be sipped slowly between meals. Using seasonings to enhance the flavor of foods is not likely to help with chemotherapyinduced nausea, and cold milk as a meal replacement may not provide enough calories and nutrients.
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