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A nurse is assisting with the care of a client.

Exhibits

Drag 1 condition and 1 finding to fill in each blank in the following sentence.

The client likely suffered from 

as evidenced by
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

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.


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Related Questions

Correct Answer is B

Explanation

A. Decrease daily fluid intake. Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, can cause hypotension, particularly after the first dose. Decreasing fluid intake could exacerbate hypotension and increase the risk of syncope. Clients should maintain adequate hydration unless otherwise instructed by their provider.
B. Rise slowly from a sitting position to a standing position. Enalapril can cause orthostatic hypotension, especially when starting therapy. Clients should be advised to change positions slowly to reduce dizziness and syncope risk. Lying down if dizziness occurs can help restore blood pressure and prevent falls.
C. Withhold the medication if pulse rate is less than 60/min. Enalapril primarily affects blood pressure rather than heart rate. Unlike beta-blockers or some calcium channel blockers, it does not significantly lower the heart rate. The decision to hold enalapril should be based on blood pressure readings rather than pulse rate.
D. Increase dietary potassium. ACE inhibitors reduce potassium excretion, increasing the risk of hyperkalemia. Clients should be cautious with potassium-rich foods and supplements to avoid dangerous elevations in potassium levels, which can lead to cardiac complications.

Correct Answer is A

Explanation

A. Can be a result of an early bowel obstruction. Hyperactive bowel sounds are characterized by loud, high-pitched, and frequent gurgling or rushing noises. They occur when there is increased intestinal motility, which can be seen in conditions such as gastroenteritis, diarrhea, or the early stages of a mechanical bowel obstruction. As the obstruction progresses, bowel sounds may become hypoactive or absent.
B. No sounds heard after listening for 3 to 5 min. This finding indicates absent bowel sounds, not hyperactive ones. Absent bowel sounds suggest complete bowel obstruction, paralytic ileus, or peritonitis and require immediate medical evaluation.
C. Sounds are soft and at a rate of 1/min. Hypoactive bowel sounds, rather than hyperactive ones, are characterized by infrequent, soft, or sluggish sounds occurring at a rate of less than 5 sounds per minute. Hypoactive bowel sounds are often associated with postoperative recovery, peritonitis, or late-stage bowel obstruction.
D. Indicates decreased motility. Hyperactive bowel sounds indicate increased, not decreased, intestinal motility. Decreased motility is associated with hypoactive or absent bowel sounds, which can occur due to conditions such as ileus, bowel obstruction, or the effects of certain medications, including opioids.

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