A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.
The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?

Decreased temperature.

Polyuria.

Bradycardia.

Increased respiratory rate.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Decreased temperature is not a typical sign of naloxone reversing the effects of an opioid overdose. Opioid overdose commonly leads to respiratory depression and hypoxia, but it does not significantly affect body temperature. Naloxone works by binding to the same receptors in the brain that opioids bind to, thereby reversing the effects of the overdose. The primary signs of successful reversal include improved respiratory rate and increased alertness, not changes in body temperature.

Choice B rationale:

Polyuria (excessive urination) is not a specific indicator of naloxone effectiveness. Opioid overdose and naloxone administration primarily affect the central nervous system and respiratory function, not urinary output. Naloxone's effects are more evident in the client's level of consciousness, respiratory rate, and overall responsiveness.

Choice C rationale:

Bradycardia (slow heart rate) is not an expected indicator of naloxone effectiveness. Opioid overdose typically causes respiratory depression, leading to a decreased respiratory rate and oxygen saturation. Naloxone works by reversing this respiratory depression and improving ventilation. Consequently, increased respiratory rate, not heart rate, is a more relevant indicator of naloxone's effectiveness in reversing opioid overdose.

Choice D rationale:

This is the correct answer. Increased respiratory rate is a key indicator that naloxone is reversing the effects of an opioid overdose. Opioid overdose depresses the respiratory system, leading to slow and shallow breathing. Naloxone, as an opioid receptor antagonist, rapidly reverses this effect, leading to a noticeable increase in the client's respiratory rate. Monitoring for improved breathing and increased oxygen saturation is crucial to assessing the effectiveness of naloxone in treating opioid overdose.

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Correct Answer is ["B","C","E","F"]

Explanation

A. Attends school regularly: While attending school regularly is important, it is not an immediate concern that requires follow-up compared to the other more pressing issues related to the traumatic event and the client's mental well-being.
B. Caregiver reporting client acting differently than usual: This finding requires immediate follow-up because it indicates a change in the client's behavior and could be indicative of emotional distress or mental health issues, especially considering the recent traumatic event they experienced.

C. Witnessing their family's death: Witnessing the death of family members in a traumatic event like a tornado is a significant and potentially traumatizing experience that requires immediate follow-up and support.
D. Heart rate 99/min: While a heart rate of 99/min is slightly elevated, it is not a critical finding that requires immediate follow-up in this context. The other findings are more relevant to the client's psychological well-being.
E. Smoking marijuana to clear their mind: The client's use of marijuana to cope with their thoughts and feelings should be addressed promptly, as it could indicate maladaptive coping mechanisms or potential substance abuse.
F. Client experiences nightmares: Experiencing nightmares could be a symptom of post-traumatic stress disorder (PTSD) or other mental health concerns related to the traumatic event.
G. BP 122/80 mm Hg: A blood pressure of 122/80 mm Hg is within a normal range and is not a cause for immediate concern.
H. Startles easy during thunderstorm: While startle responses can be related to anxiety, this specific finding is not as pressing as the client's reported coping mechanisms and traumatic experiences.

A. The client is unable to obey commands. B. The client is oriented times three. C. The client opens eyes to sound. D. The client withdraws from pain.

Correct Answer is B

Explanation

A. Incorrect. A Glasgow coma scale (GCS) rating of 15 indicates that the client is able to obey commands.
B. Correct. A GCS rating of 15 indicates that the client is fully conscious and oriented to person, place, and time.
C. Incorrect. Opening eyes to sound is a response associated with the eye-opening component of the GCS score, but this response does not provide information about the client's orientation.
D. Incorrect. Withdrawing from pain is a response associated with the motor component of the GCS score, but this response does not provide information about the client's orientation.

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A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E","F"]

Explanation

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Correct Answer is B

Explanation

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A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.
The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?