A nurse is caring for a client in an outpatient clinic.

Exhibits

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Nurses' Notes

3 months ago:

61-year-old male client presents with reports of dizziness, palpitations, fatigue. and dyspnea with exertion. Reports that dizziness and palpitations started 2 months ago. Fatigue and dyspnea with exertion started 1 week ago. Has smoked 1 pack of cigarettes per day for 40 years.

Past medical history.

History of hyperlipidemia.

Walks at least a mile three times a week. Reports drinking two to three beers each evening

Client reports he follows the Dietary Approaches to Stop Hypertension (DASH) diet.

Family history.

Biological father has a history of hyperlipidemia and hypertension. Biological mother has history of renal failure requiring dialysis.

Physical examination:

• Weight 88.6 kg (195.3 lb)
• Height 170.2 cm (5 ft 7 in)
• BMI 30.5

Rationale:

A. "You will receive a dose of misoprostol to initiate contractions.": Misoprostol is used for cervical ripening and induction of labor, not for a contraction stress test. A CST uses nipple stimulation or low-dose oxytocin to produce mild contractions. Using misoprostol would create strong, prolonged contractions that could endanger the fetus.

B. "I will apply an external fetal heart rate monitor during the test.": A contraction stress test evaluates how the fetal heart rate responds to contractions. External fetal monitoring is required to record the fetal heart pattern and contraction frequency, allowing the provider to assess for late decelerations that indicate uteroplacental insufficiency. This reflects accurate and essential teaching for the procedure.

C. "I will give you a terbutaline injection after the test.": Terbutaline is a tocolytic used to stop contractions, but it is not routinely administered after a CST. The contractions produced during a CST are mild and temporary, and terbutaline is only given if excessive contractions occur, which is not expected in normal testing.

D. "I will apply an oxygen face mask during the test.": Oxygen is not routinely administered during a CST because the goal is to observe how the fetus tolerates normal physiologic contractions. Oxygen is used only if fetal distress occurs, so including it in routine teaching suggests an incorrect understanding of the procedure.

Rationale for Correct Choices

• opioid intoxication: The client is drowsy, difficult to arouse, and has a respiratory rate of 10/min, all of which are hallmark findings of opioid intoxication. The presence of a needle in the antecubital space and the need for naloxone also strongly support opioid involvement. The prior history also documents opioid misuse and prior treatment with buprenorphine/naloxone, further increasing the likelihood of opioid intoxication in this episode.

• pupil characteristics: Miotic (pinpoint) pupils are a classic indicator of opioid intoxication and help differentiate it from alcohol intoxication, which typically presents with normal or enlarged pupils. The pupil response directly supports the diagnosis when paired with respiratory depression and altered level of consciousness.

Rationale for Incorrect Choices

• Alcohol withdrawal: Alcohol withdrawal presents with agitation, tremors, diaphoresis, tachycardia, hypertension, and occasionally hallucinations. This client is drowsy with decreased respiratory rate and constricted pupils, which are inconsistent with alcohol withdrawal, making this diagnosis unlikely.

• Alcohol intoxication: Alcohol intoxication often presents with slurred speech, ataxia, and altered mental status, but pupils are usually normal in size and not constricted. There is also no evidence of significant alcohol consumption reported, making alcohol intoxication less likely in this scenario.

• Opioid withdrawal: Opioid withdrawal is characterized by mydriasis (dilated pupils), diaphoresis, piloerection, tachycardia, nausea, vomiting, and agitation. The client’s current presentation of drowsiness, miotic pupils, and respiratory depression is opposite of withdrawal symptoms, ruling out opioid withdrawal.

• Amount of alcohol consumed: The client reportedly had only one beer, which is insufficient to cause coma-level depression. Alcohol intoxication severe enough to cause unresponsiveness with respiratory depression would require significantly higher intake.

• Breath sounds: Clear breath sounds do not help distinguish the cause of the altered mental status. Breath sounds are more useful for identifying respiratory complications, not for differentiating intoxication types.

• Current temperature: A normal temperature does not help identify opioid intoxication versus withdrawal. Temperature fluctuations are more common in severe withdrawal states and are not diagnostic enough to determine the underlying cause in this scenario.