A nurse is caring for a client in the emergency department (ED)

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct choices:

Opioid intoxication: The client exhibits classic signs of opioid overdose, including shallow respirations, bradypnea, bradycardia, hypotension, hypothermia, slurred speech, and constricted pupils. These findings, combined with a history of oxycodone use, indicate opioid intoxication requiring immediate intervention.
Obtain a prescription for naloxone: Naloxone is an opioid antagonist that reverses the respiratory depression, sedation, and other life-threatening effects of opioid overdose. Timely administration can prevent respiratory failure and death.
Prepare to initiate mechanical ventilation: The client’s respiratory rate is critically low (10/min) with oxygen saturation at 90%, indicating inadequate ventilation. Mechanical ventilation may be required to maintain oxygenation and prevent hypoxia while naloxone takes effect.
Pupillary reaction: Monitoring pupillary constriction or dilation helps assess the client’s response to opioid reversal therapy and can indicate ongoing central nervous system depression or improvement.
Respiratory rate: Continuous monitoring of respiratory rate is essential because hypoventilation is the most immediate life-threatening effect of opioid intoxication. Changes indicate whether interventions like naloxone or ventilation are effective.

Rationale for incorrect choices:

Alcohol intoxication: Although the client has a history of alcohol use disorder, the current symptoms of miosis, hypoventilation, and hypotension are more consistent with opioid toxicity rather than acute alcohol intoxication.
Opioid withdrawal: Withdrawal presents with agitation, tachypnea, hypertension, dilated pupils, diaphoresis, and GI upset. This client’s bradycardia, hypotension, and hypoventilation indicate intoxication, not withdrawal.
Stimulant intoxication: Stimulant overdose typically presents with hypertension, tachycardia, hyperthermia, and agitation. The client’s hypotension, bradycardia, and CNS depression are inconsistent with stimulant use.
Anticipate administering clonidine: Clonidine is used for opioid withdrawal management, not acute intoxication. Administering it in this scenario would not address the life-threatening hypoventilation or CNS depression.
Collect a blood sample for ethanol level: While it may be helpful for history, ethanol testing does not address the immediate life-threatening opioid overdose and is not a priority intervention.
Obtain prescription for restraints: There is no indication for restraints. The client’s symptoms are due to CNS depression, and restraints would not improve their condition and could worsen injury risk.
Hyperreflexia: This is a sign of opioid withdrawal or CNS stimulant activity, not opioid intoxication. The client’s deep tendon reflexes are decreased, consistent with CNS depression.
Cardiac arrhythmias: While arrhythmias can occur, there is no evidence in this assessment of dysrhythmias. Monitoring vital signs and oxygenation is more immediately critical.

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Correct Answer is A

Explanation

A. Tell the client, "You seem to be very upset.": Using verbal de-escalation and acknowledging the client’s emotions can help reduce agitation. This approach demonstrates empathy, promotes communication, and can prevent escalation.

B. Use a face shield with a mask when providing care to the client: Personal protective equipment is important for infection control, but it does not address the behavioral escalation or help calm an agitated client.

C. Initiate seclusion protocol: Seclusion is a restrictive intervention used only if the client poses an imminent risk of harm. It is not the first step in managing agitation and should follow attempts at de-escalation.

D. Engage the panic alarm: Activating the panic alarm is appropriate in situations of immediate danger, but for verbal agitation and pacing without aggression, de-escalation is the first intervention.

A. Choose high-fat cheese as a meat substitute. B. Choose foods high in vitamin B12 C. Limit intake of foods high in vitamin C. D. Limit intake of nuts and legumes.

Correct Answer is B

Explanation

Rationale:

A. Choose high-fat cheese as a meat substitute: Cheese is an animal-derived product and not part of a vegan diet. Additionally, it is high in saturated fat, which can contribute to cardiovascular risk.

B. Choose foods high in vitamin B12: Vitamin B12 is primarily found in animal products, so vegans are at risk for deficiency. Including fortified foods or supplements helps prevent anemia and neurological complications.

C. Limit intake of foods high in vitamin C: Vitamin C-rich foods are beneficial for overall health and can improve non-heme iron absorption from plant sources. There is no reason to limit these foods in a vegan diet.

D. Limit intake of nuts and legumes: Nuts and legumes are excellent plant-based sources of protein, healthy fats, and micronutrients. Restricting them would reduce the nutritional adequacy of a vegan diet.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

Correct Answer is A

Explanation

A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following information should the nurse include?

Correct Answer is B

Explanation

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