A nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data from the client.

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

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and

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indicate manifestations of borderline personality disorder.

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C. "I have noticed that my child is withdrawn since we switched day care providers."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.

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.