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A nurse is assisting with the care of a client.

Select 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":"C","dropdown-group-2":"D"}

  • alcohol intoxication: Although the client consumed one beer, this small amount is unlikely to cause unresponsiveness, respiratory depression, or the need for naloxone administration. Alcohol intoxication alone does not explain the profound sedation and pinpoint pupils observed.
  • alcohol withdrawal: Alcohol withdrawal typically presents with signs like agitation, tremors, hallucinations, and seizures, not sedation, miosis, and depressed respiratory drive. The client’s symptoms are inconsistent with alcohol withdrawal.
  • hallucinogen intoxication: Hallucinogen use usually leads to agitation, paranoia, hallucinations, and dilated pupils (mydriasis), not the sedated state, respiratory depression, and miotic pupils that this client is exhibiting.
  • opioid intoxication: The client's unresponsiveness, respiratory depression, and pinpoint pupils, combined with a positive response to naloxone, are classic indicators of opioid intoxication. These findings directly align with the expected effects of opioid overdose.
  • opioid withdrawal: Opioid withdrawal presents with signs like agitation, mydriasis, diarrhea, piloerection, and flu-like symptoms. The client’s current state of sedation and miotic pupils contradicts what would be seen during opioid withdrawal.
  • amount of alcohol consumed: The small amount of alcohol (one beer) does not correlate with the severity of the client’s clinical presentation. Thus, alcohol consumption is not the primary factor contributing to the current state.
  • breath sounds: Breath sounds are clear and equal bilaterally, indicating that the lungs are not the source of the client's critical condition. There is no evidence of respiratory infection or pulmonary complications.
  • abdominal findings: Decreased bowel sounds are common in opioid intoxication due to decreased gastrointestinal motility. However, while supportive, this finding is less definitive than the hallmark sign of pupil constriction.
  • pupil characteristics: The presence of pinpoint pupils (miosis) is a hallmark sign of opioid intoxication. Miotic pupils, especially in an unresponsive client who improved after naloxone, strongly support opioid overdose as the primary diagnosis.
  • current temperature: The client's temperature is within normal limits, providing no significant diagnostic clue toward explaining the cause of unresponsiveness or respiratory depression.


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Related Questions

Correct Answer is C

Explanation

A. Auscultate the client's lung sounds: While lung sounds are important to assess in clients with heart failure, auscultating lung sounds is not directly required before administering digoxin. The immediate concern with digoxin is its effect on heart rate and rhythm.

B. Check the client's weight: Monitoring weight is important in heart failure management to assess fluid retention, but weight measurement is not necessary immediately prior to administering a dose of digoxin.

C. Check the client's apical pulse: Before giving digoxin, it is critical to assess the client's apical pulse for one full minute. If the pulse is below a specified rate (60 beats/min for adults), the dose may need to be withheld and the provider notified due to the risk of digoxin-induced bradycardia.

D. Obtain the client's oxygen saturation: Oxygen saturation is important in evaluating respiratory function, but it is not a priority action before administering digoxin. The primary safety check is heart rate assessment.

Correct Answer is C

Explanation

A. The infant was born large for gestational age: Being large for gestational age is not recognized as a risk factor for child maltreatment. Risk factors are more often related to family dynamics, age, and social stressors rather than birth weight alone.

B. The infant has otitis media: Otitis media, or a middle ear infection, is a common pediatric illness and is not itself a risk factor for maltreatment. It reflects normal childhood health issues rather than abuse or neglect.

C. The infant is younger than 1 year of age: Infants under 1 year are particularly vulnerable to maltreatment because of their total dependence on caregivers and inability to communicate effectively. This age group is at the highest risk for serious injury from abuse.

D. The infant's guardians are both over the age of 30: Parental age over 30 does not inherently increase the risk for child maltreatment. Other factors like substance abuse, history of being abused, and high stress levels are more closely linked to maltreatment risk.

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