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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 A

Explanation

A. Abnormal Involuntary Movement Scale. The Abnormal Involuntary Movement Scale (AIMS) is a validated tool specifically designed to assess and identify tardive dyskinesia in clients taking antipsychotic medications. The AIMS evaluates the presence, frequency, and severity of involuntary movements, providing a structured approach for monitoring and documenting these symptoms over time.
B. Brief Psychiatric Rating Scale. The Brief Psychiatric Rating Scale (BPRS) is utilized to assess a range of psychiatric symptoms, including depression, anxiety, and psychosis. However, it does not specifically address the assessment of abnormal involuntary movements associated with tardive dyskinesia. Therefore, while it is useful for general psychiatric evaluation, it is not appropriate for identifying tardive dyskinesia.
C. Patient Health Questionnaire-9. The Patient Health Questionnaire-9 (PHQ-9) is a widely used screening tool for assessing the severity of depression. It focuses on mood-related symptoms and does not evaluate movement disorders or side effects of antipsychotic medications. As such, it is not relevant for identifying tardive dyskinesia.
D. Mental Status Examination. The Mental Status Examination (MSE) provides a comprehensive assessment of a client’s cognitive and emotional state, covering areas such as appearance, behavior, thought processes, and mood. While the MSE is valuable for overall psychiatric evaluation, it does not specifically assess for tardive dyskinesia or abnormal involuntary movements, making it unsuitable for this purpose.

Correct Answer is B

Explanation

A. "Anticipate that the insulin glargine will peak in 3 hours." Insulin glargine is a long-acting basal insulin with no pronounced peak. Instead, it provides a steady level of insulin over 24 hours, reducing the risk of hypoglycemia. Unlike short- or intermediate-acting insulins, it does not have a defined peak time.
B. "Draw up the insulin lispro and insulin glargine in separate syringes." Insulin glargine should never be mixed with other insulins in the same syringe, as it has a unique pH that can cause precipitation when combined. Insulin lispro, a rapid-acting insulin, can be mixed with some other insulins, but it must be drawn up separately from insulin glargine to maintain its stability and effectiveness.
C. "Expect insulin glargine to be cloudy." Insulin glargine is a clear solution. Cloudy insulins, such as NPH (neutral protamine Hagedorn), require gentle rolling before administration to mix the suspension evenly. If insulin glargine appears cloudy, it may be contaminated or compromised and should not be used.
D. "Take an extra dose of insulin lispro prior to aerobic exercise." Taking extra insulin lispro before exercise can increase the risk of hypoglycemia, as physical activity naturally lowers blood glucose levels. Clients with diabetes should monitor their blood glucose before, during, and after exercise and may need to adjust their carbohydrate intake rather than taking additional insulin.

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