A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

dropdown

and then

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Rationale:

• Opioid intoxication. The client was found unresponsive with a needle in the left antecubital space, suggesting recent intravenous drug use. The administration of naloxone, an opioid antagonist, further supports opioid intoxication as the likely condition. Additionally, the client presents with decreased level of consciousness, respiratory depression (respiratory rate of 10/min), and decreased bowel sounds, all of which are classic signs of opioid intoxication.
• Pupil characteristics
  The client’s pupils are miotic (constricted), which is a hallmark sign of opioid intoxication due to the drug’s effect on the parasympathetic nervous system. Opioids, particularly heroin and prescription narcotics, cause pinpoint pupils, which can help differentiate opioid intoxication from other conditions that may cause altered mental status.

Rationale for Incorrect Options:

• Opioid withdrawal is characterized by symptoms such as agitation, dilated pupils, diarrhea, and tachycardia, none of which are present in this client. Instead, the client exhibits signs of central nervous system depression rather than hyperactivity, making withdrawal unlikely.
• Hallucinogen intoxication typically presents with hallucinations, paranoia, agitation, and altered sensory perception. The client’s presentation does not include these findings, making hallucinogen intoxication an unlikely cause.
• Alcohol intoxication is associated with slurred speech, ataxia, and confusion, but the client’s history indicates only one beer was consumed, which is not enough to cause such profound central nervous system depression. The presence of a needle and response to naloxone further support opioid intoxication rather than alcohol intoxication.
• Alcohol withdrawal presents with symptoms such as tremors, tachycardia, hypertension, and agitation. The client is instead experiencing respiratory depression and sedation, which are inconsistent with alcohol withdrawal.

A. Encourage the client to use the overbed trapeze. Using an overbed trapeze helps the client build upper body strength, which is essential for mobility and independence following an amputation. Strengthening the arms and shoulders facilitates bed mobility, transfers, and eventual prosthetic use.
B. Keep a loose, absorbent dressing over the client's surgical site. The surgical site should be covered with a secure, sterile dressing to promote healing and prevent infection. Loose dressings can shift, increasing the risk of contamination and delayed wound healing.
C. Maintain abduction of the client's residual limb with a pillow. Prolonged abduction is not recommended, as it can lead to hip contractures. The limb should be kept in a neutral or slightly extended position to maintain proper alignment and prevent muscle shortening that could interfere with prosthetic use.
D. Caution the client to avoid a prone position while in bed. Prone positioning is actually encouraged intermittently to help stretch the hip flexors and prevent contractures. Avoiding this position may increase the risk of hip flexion contractures, making prosthetic fitting and ambulation more difficult.