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 ["A","D","E","G","H"]
Explanation
A. Current medications. The client is taking ibuprofen 800 mg three times daily, which is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastric mucosal injury, leading to peptic ulcers and gastrointestinal bleeding. Given the client's symptoms and history of dark, tarry stools, the use of NSAIDs requires immediate follow-up to prevent further complications.
B. Respiratory rate. The client’s respiratory rate is 18/min, which is within the normal range (12 to 20/min). This finding does not require immediate follow-up.
C. WBC count. The WBC count is 6,700/mm³, which falls within the normal range (5,000 to 10,000/mm³). There is no indication of an active infection or leukocytosis requiring urgent intervention.
D. Heart rate. The heart rate is 118/min, which is elevated and suggests tachycardia. This could be a compensatory response to hypovolemia from gastrointestinal bleeding. Immediate follow-up is necessary to prevent hemodynamic instability.
E. Stool results. The stool test is positive for occult blood, indicating gastrointestinal bleeding. This finding requires immediate follow-up to determine the severity of bleeding and prevent further blood loss.
F. Temperature. The client’s temperature is 37.5°C (99.5°F), which is within the normal range. There is no indication of fever or infection, so this does not require immediate intervention.
G. Blood pressure. The blood pressure is 90/50 mm Hg, which is low and may indicate hypovolemia due to gastrointestinal blood loss. Hypotension combined with tachycardia is a concerning sign that requires urgent intervention.
H. Hemoglobin and hematocrit. The hemoglobin (9.1 g/dL) and hematocrit (27%) are low, suggesting anemia likely due to chronic blood loss. This requires immediate follow-up to assess for continued bleeding and the need for interventions such as fluid resuscitation or blood transfusion.
Correct Answer is D
Explanation
A. Docusate. Docusate is a stool softener that helps prevent constipation, which can be beneficial for clients taking enoxaparin, as straining during bowel movements can increase the risk of bleeding. It does not have anticoagulant properties and does not pose a significant risk of increased bleeding.
B. Cimetidine. Cimetidine, an H2-receptor antagonist used to reduce stomach acid, does not directly increase bleeding risk. However, long-term use can affect liver metabolism and interact with some anticoagulants, but it is not considered unsafe for routine use with enoxaparin.
C. Calcium supplement. Calcium supplements are commonly used for bone health and do not interfere with enoxaparin’s anticoagulant effects. They do not increase bleeding risk and are generally safe for clients taking anticoagulants.
D. Naproxen. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation and increases the risk of gastrointestinal bleeding. When combined with enoxaparin, which is a low-molecular-weight heparin, the risk of bleeding complications, including gastrointestinal and intracranial hemorrhage, significantly increases. Clients should be advised to use acetaminophen for pain relief instead of NSAIDs while taking enoxaparin.
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