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 C
Explanation
A. "My child still wets the bed at least two times per week." Bedwetting (nocturnal enuresis) is common in young children, and while it can be concerning, it is not uncommon for a 4-year-old. Many children still experience bedwetting at this age, and it usually resolves over time.
B. "My child continually asks me the same questions." Continually asking the same questions can be typical for a 4-year-old, as children often seek clarification and reassurance through repetitive questioning. While it may be frustrating, it is generally not a sign of a serious issue.
C. "I have noticed that my child is withdrawn since we switched day care providers." Withdrawal can be a sign of emotional distress, anxiety, or adjustment issues related to the change in daycare. The nurse should further assess the child's emotional and behavioral responses to ensure they are receiving the appropriate support and intervention if needed.
D. "I have a difficult time getting my child to eat green vegetables." Getting the child to eat green vegetables is a common challenge among young children, as they often exhibit food preferences and may be picky eaters. While it is important to encourage healthy eating habits, this issue does not require immediate intervention compared to concerns about emotional withdrawal.
Correct Answer is C
Explanation
A. Obtain written consent by the client for the placement of the restraints. It is not typically required to obtain written consent from the client for the use of restraints. However, consent may be necessary for treatment in general, depending on the facility's policies and state laws. Restraints are usually applied to ensure safety and must be justified based on the client's behavior.
B. Release the client's restraints every 4 hr. Restraints should be released more frequently, typically every 1 to 2 hours, to assess the client's safety and physical condition and to allow for movement, hydration, and toileting as appropriate.
C. Document the client's behavior leading to the initiation of the restraints. Documenting the client's behavior that necessitated the use of restraints is crucial for legal and ethical reasons. This documentation provides a clear rationale for the use of restraints and helps ensure compliance with facility policies and regulations.
D. Check the client's status every hour. The client's status should be checked more frequently than every hour. Regular monitoring is essential to ensure the client's safety, comfort, and physical well-being while in restraints. The nurse should assess the client every 15 to 30 minutes based on facility protocols.
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