A nurse is assisting in the admission of a client who had recently given birth and is presenting to the emergency department with acute opioid toxicity. Which of the following findings should the nurse expect?
Hypothermia.
Hypertension.
Diaphoresis.
Mydriasis.
The Correct Answer is A
Choice A reason:
Hypothermia. Hypothermia refers to a condition where the body temperature drops significantly below the normal range. However, in cases of acute opioid toxicity, the opposite effect is usually observed. Opioids can cause respiratory depression, leading to a decrease in the body's ability to regulate temperature, resulting in hyperthermia, not hypothermia.
Choice B reason:
Hypertension. Acute opioid toxicity typically causes respiratory depression, which can lead to a decrease in blood pressure rather than hypertension. Opioids are central nervous system depressants that slow down the body's vital functions, including heart rate and blood pressure.
Choice C reason:
Diaphoresis. Diaphoresis is the medical term for excessive sweating. While it may occur in some cases of opioid toxicity due to the body's response to stress or increased sympathetic activity, it is not a specific and consistent finding. It is not as characteristic as other symptoms associated with opioid toxicity.
Choice D reason:
Mydriasis. Mydriasis refers to the dilation of the pupils. This is a hallmark sign of opioid toxicity. Opioids can affect the autonomic nervous system, leading to pupillary constriction (miosis) in most cases. However, when opioid toxicity is severe or acute, the pupils may dilate, resulting in mydriasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Washing off the zinc oxide ointment with each diaper change would not be beneficial for the infant's diaper dermatitis. Zinc oxide ointment forms a protective barrier on the skin, and frequent washing could remove this barrier, reducing its effectiveness in promoting healing and protecting the irritated skin.
Choice B reason:
Shaking talcum powder onto the reddened areas is not a suitable approach. Talcum powder can further irritate the skin and worsen the diaper dermatitis. It is best to avoid using talcum powder on an infant's delicate skin.
Choice C reason:
Using a hair dryer, even on the lowest setting, to dry the diaper area is not recommended. The hot air from the hair dryer can be too harsh for the infant's sensitive skin and might exacerbate the irritation. It is safer to let the diaper area air dry naturally or pat it gently with a soft cloth.
Choice D reason:
This is the correct choice. Using moist disposable wipes that are detergent-free is a suitable option for cleaning the infant's diaper area. Detergent-free wipes are gentle on the skin and less likely to cause further irritation. Additionally, keeping the area clean and dry is essential for managing diaper dermatitis, and these wipes can help achieve that without causing harm.
Correct Answer is C
Explanation
Choice A reason:
The FACES Scale is a visual pain scale typically used for children who can understand and verbalize their pain intensity. It consists of a series of faces with varying expressions, from smiling to crying, to help the child express their pain level. However, since the client in question is nonverbal and has cognitive and developmental delays, this scale may not be suitable as they might not be able to communicate using this tool effectively.
Choice B reason:
The Numerical Scale involves asking the patient to rate their pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. While this scale is commonly used for older children and adults, it may not be appropriate for a nonverbal and developmentally delayed 9-year-old client, as they may not understand or be able to use numbers effectively to express their pain.
Choice C reason:
The FLACC pain assessment scale is designed for nonverbal or preverbal individuals, including children and those with cognitive impairments. FLACC stands for Face, Legs, Activity, Cry, and Consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the version used, based on specific observed behaviors. The scores are then totaled to give an overall pain assessment. This scale is particularly suitable for the current client's condition as it focuses on observable behaviors rather than verbal communication.
Choice D reason:
The Visual Analog Scale (VAS) requires the patient to mark a point along a line that represents their pain intensity, with one end indicating no pain and the other end indicating the worst pain. Although this scale is useful for older children and adults, it may not be appropriate for a 9-year-old client with cognitive and developmental delays who might not fully comprehend the concept of the scale.
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