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 A
Explanation
"I should start trying to breastfeed within an hour of having my baby.” Choice A reason:
The client's statement indicates an understanding of the teaching because initiating breastfeeding within the first hour after birth is crucial for successful breastfeeding. This early initiation allows the baby to receive colostrum, which is rich in nutrients and antibodies, supporting the baby's immune system and providing essential nutrition during the initial stages of life. Additionally, early breastfeeding helps establish a strong bond between the mother and the baby while promoting the baby's suckling reflex.
Choice B reason:
The statement in Choice B is incorrect. Formula feeding between breastfeedings is not recommended in the early stages of breastfeeding, especially if the baby loses 5 percent of their birth weight. Newborns often lose some weight initially, which is normal, and it can be regained through effective breastfeeding. Supplementing with formula may interfere with establishing a good milk supply and the baby's ability to latch properly.
Choice C reason:
This statement in Choice C is incorrect. During breastfeeding sessions, it's essential for the baby to nurse on one breast fully before switching to the other breast. Allowing the baby to nurse for at least 10-15 minutes on each breast ensures they receive the hindmilk, which is higher in fat and essential for the baby's growth and development.
Choice D reason:
The statement in Choice D is incorrect. Offering a pacifier right after breastfeeding might interfere with the baby's feeding cues and lead to decreased breastfeeding frequency.
Newborns may suck for non-nutritive reasons, and offering a pacifier too soon can hinder proper breastfeeding establishment, as they may satisfy their sucking needs with the pacifier rather than nursing at the breast.
Correct Answer is B
Explanation
Choice A reason:
Airborne precautions are implemented for diseases that spread through small airborne particles, such as tuberculosis or measles. These diseases can remain suspended in the air for extended periods and be inhaled by others. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets when an infected person coughs or sneezes, making airborne precautions unnecessary.
Choice B reason:
Droplet precautions are appropriate for illnesses that spread through respiratory droplets produced when an infected person talks, coughs, or sneezes. Pertussis falls into this category as it is transmitted mainly through respiratory droplets. By implementing droplet precautions, the nurse will minimize the risk of transmission to others, including healthcare workers and other patients.
Choice C reason:
Standard precautions are the baseline infection prevention practices used for all patients to prevent the spread of infections in healthcare settings. While important, they may not be sufficient to control the transmission of pertussis, as it requires additional measures like droplet precautions due to its specific mode of transmission.
Choice D reason:
Neutropenic precautions are used for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). The purpose is to protect these vulnerable individuals from exposure to infectious agents. However, pertussis precautions are different and do not fall under the neutropenic category.
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