A nurse is assisting with the care of a client.
Drag 1 condition and 1 finding to fill in each blank in the following sentence.
The client likely suffered from
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Justice." Justice refers to fairness in the distribution of resources, treatment, and care. It involves ensuring that all clients receive equal and appropriate care based on their needs. While justice is an important ethical principle, it is not directly related to the nurse’s promise to walk with the client.
B. "Nonmaleficence." Nonmaleficence is the obligation to do no harm. This principle guides nurses in preventing injury, minimizing risks, and ensuring client safety. While supporting the client can help reduce anxiety, the nurse’s action primarily reflects a different ethical principle.
C. "Autonomy." Autonomy refers to respecting a client’s right to make their own decisions regarding their care. The nurse should encourage autonomy by allowing the client to choose whether to walk in the courtyard, but the act of making a promise to accompany them aligns more closely with a different ethical principle.
D. "Fidelity." Fidelity involves keeping promises and being truthful in professional relationships. By committing to walk with the client daily and following through on that promise, the nurse is demonstrating fidelity by building trust and maintaining professional integrity.
Correct Answer is C
Explanation
A. Beneficence. Beneficence refers to the ethical obligation to promote the well-being of clients and take actions that benefit them. While providing medication education supports the client's health, the primary ethical principle demonstrated in truthfully explaining adverse effects is veracity, not beneficence.
B. Justice. Justice involves fairness in the distribution of resources, treatment, and care. It ensures that all clients receive equitable care regardless of personal or socioeconomic differences. While justice is a fundamental ethical principle, it does not directly relate to truthfulness in medication education.
C. Veracity. Veracity is the ethical principle of honesty and truthfulness in communication with clients. By truthfully informing the client about the adverse effects of their prescribed medications, the nurse upholds veracity, ensuring the client has accurate information for informed decision-making.
D. Autonomy. Autonomy refers to the client’s right to make informed decisions about their care. While providing truthful information supports autonomy, the ethical concept the nurse demonstrates in this scenario is veracity, as the focus is on truthfully sharing medication information.
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