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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Correct Answer is C

Explanation

A. "Your baby needs to suck on a pacifier.": While non-nutritive sucking on a pacifier can sometimes soothe a fussy baby, it is not the first recommendation, especially for a newborn who is establishing breastfeeding. Early introduction of pacifiers can interfere with successful breastfeeding due to nipple confusion.

B. "Breastfed babies are usually fussy from swallowing too much air during feedings.": Although some air swallowing can occur, especially if the latch is poor, this is not typically the primary reason for persistent crying. Addressing crying with soothing techniques like swaddling is a more immediate and supportive intervention for the parent.

C. "Swaddling your baby snugly in a blanket might help soothe her.": Swaddling provides warmth, security, and a sense of being back in the womb, which can calm a newborn effectively. It reduces the startle reflex and helps regulate the baby's nervous system, often resulting in decreased crying and improved comfort.

D. "Breastfed babies often need to be supplemented with formula.": Routine supplementation with formula is not recommended for healthy breastfed newborns unless there are clear medical indications. Promoting exclusive breastfeeding supports optimal nutrition, bonding, and gut health in the early postpartum period.

A. Changing a sterile dressing for a client who is postoperative B. Performing a gastrostomy feeding on a stable client C. Observing the patency of an intravenous catheter on a stable client D. Providing postmortem care to a client

Correct Answer is D

Explanation

A. Changing a sterile dressing for a client who is postoperative: Changing a sterile dressing requires the use of sterile technique and nursing judgment, making it a task that must be performed by a licensed nurse, not delegated to assistive personnel.

B. Performing a gastrostomy feeding on a stable client: While assistive personnel can assist with feeding in general, administering a gastrostomy feeding requires specific assessment and verification of tube placement, which must be done by a licensed nurse.

C. Observing the patency of an intravenous catheter on a stable client: Observing and assessing IV catheter patency is a nursing responsibility. It requires assessment skills and cannot be delegated to assistive personnel.

D. Providing postmortem care to a client: Providing postmortem care, such as bathing, positioning, and preparing the body, is a task that can be safely delegated to assistive personnel, following proper facility protocols and respectful handling of the deceased.

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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 _______

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, "My baby won't stop crying even though I've changed her diaper and breastfed her." Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

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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
_