A nurse is assisting with the care of a client who last used heroin 8 hr ago. Which of the following findings should the nurse identify as a manifestation of opioid withdrawal?
Tachycardia
Miosis
Hypotension
Sedation
The Correct Answer is A
A. Tachycardia: Tachycardia, or an increased heart rate, is a common manifestation of opioid withdrawal. Withdrawal stimulates the sympathetic nervous system, leading to symptoms like tachycardia, sweating, anxiety, and restlessness.
B. Miosis: Miosis, or pinpoint pupils, is associated with opioid intoxication, not withdrawal. During withdrawal, pupils are often dilated (mydriasis) rather than constricted.
C. Hypotension: Hypertension, not hypotension, is more commonly seen during opioid withdrawal due to increased sympathetic nervous system activity. Blood pressure tends to rise rather than fall during withdrawal episodes.
D. Sedation: Sedation is a sign of opioid intoxication rather than withdrawal. Clients experiencing withdrawal are more likely to display agitation, irritability, and insomnia rather than drowsiness or sedation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Medication: The medication, erythromycin, is clearly stated and appropriately spelled. There is no confusion about what drug the provider intended to prescribe, so there is no immediate need to clarify the medication name itself.
B. Route: The prescription does not specify the route of administration, which is essential for safe medication delivery. Erythromycin can be given orally or intravenously, and using the wrong route could lead to serious complications. Clarifying the route ensures proper technique and absorption.
C. Dosage: The dosage of 500 mg is within the standard therapeutic range for erythromycin, depending on the severity and type of infection. Since the dose appears appropriate, it does not require immediate clarification unless clinical concerns arise.
D. Time: Although "four times per day" is broad, it is generally understood as approximately every six hours. While more exact times can improve consistency, missing the route of administration is a more critical and urgent issue to clarify for client safety.
Correct Answer is C
Explanation
A. "You will also find he will want to wear girls' clothes, including dresses, as well.": This response incorrectly assumes that playing with dolls predicts future behavior regarding gender expression, which is not accurate. It also may cause unnecessary worry for the parent.
B. "Gender identity is generally not established until the child is around five years old.": While partially true, this response does not directly address the parent's concern about the current behavior. It misses the opportunity to explain that imitating caregiving is a normal developmental stage.
C. "At two years of age, toddlers often engage in play that imitates adult actions.": This response correctly explains that toddlers naturally mimic the behavior they observe in adults, including caregiving activities, without it indicating future gender identity. Play is a normal part of development at this age.
D. "When a male toddler chooses to play with dolls, it is an indication he will later identify as a female.": This statement is inaccurate and misleading. A toddler’s choice of toys reflects curiosity and imitation, not a prediction of future gender identity or roles.
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