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A nurse is caring for a client on the medical surgical unit.

Click to highlight the findings at 1630 that require immediate follow-up. To deselect a finding, click on the finding again.

Body System

Findings

Cardiovascular

S1, S2, no murmur, bradycardia

Respiratory

decreased respiratory effort, equal chest expansion, bilateral crackles

Neurologic

somnolent

Head, Ears, Eyes, Nose, and Throat (HEENT)

oropharynx clear, mucous membranes moist, pinpoint pupils

Vital Signs

Temperature 37.4° C (99.4° F)

Heart rate 58/min

Respiratory rate 10/min

Blood pressure 98/58 mm Hg

S1, S2, no murmur, bradycardia

decreased respiratory effort

equal chest expansion, bilateral crackles

somnolent

oropharynx clear,

mucous membranes moist

pinpoint pupils

Respiratory rate 10/min

Blood pressure 98/58 mm Hg

Heart rate 58/min

Answer and Explanation

The Correct Answer is ["B","D","G","H","I"]

Decreased respiratory effort, bilateral crackles: Reduced respiratory effort following opioid administration suggests opioid-induced respiratory depression. Crackles may indicate early airway compromise due to poor ventilation or fluid accumulation, requiring immediate intervention to support breathing.
Somnolent: Somnolence beyond expected postoperative drowsiness, especially in combination with other signs of opioid overdose, indicates central nervous system depression. The client is difficult to arouse, raising concern for airway and breathing compromise.
Pinpoint pupils: Pinpoint pupils are a hallmark sign of opioid toxicity. In the setting of recent morphine administration and accompanying respiratory depression, this finding confirms that opioid overdose is likely occurring and must be treated promptly.
Respiratory rate 10/min: A respiratory rate under 12 breaths per minute following opioid administration is a major red flag for opioid-induced respiratory depression. Immediate action is needed to prevent further decline in respiratory status, including potential use of naloxone.
Blood pressure 98/58 mm Hg: The client’s blood pressure has dropped significantly compared to the earlier reading, suggesting opioid-related hypotension. While not yet critically low, the trend combined with other overdose signs indicates instability needing close monitoring and intervention.
Heart rate 58/min: Although the client is bradycardic, this alone is not the most urgent issue compared to respiratory depression and neurological decline. It should still be monitored closely, but it is less immediately life-threatening than the airway and breathing concerns.
Temperature 37.4° C (99.4° F): This temperature is within normal range and does not require follow-up. There are no indications of infection or thermoregulatory issues based on the current temperature.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is "{\"xRanges\":[111.828125,122.828125],\"yRanges\":[106.5,117.5]}"

Explanation

A: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.

B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.

C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.

A. Perfectionistic B. Reclusive C. Impulsive D. Submissive

Correct Answer is D

Explanation

A. Perfectionistic: Perfectionism is more characteristic of obsessive-compulsive personality disorder, where individuals are overly focused on order, control, and achieving flawless standards. Clients with dependent personality disorder are more focused on relying on others for decision-making rather than striving for perfection.

B. Reclusive: Being reclusive, or socially withdrawn, is a common feature of avoidant personality disorder, not dependent personality disorder. Clients with dependent personality disorder typically seek out and maintain close relationships because they have an intense fear of being alone and unable to care for themselves.

C. Impulsive: Impulsivity is commonly associated with borderline personality disorder, where individuals act without considering consequences. Clients with dependent personality disorder tend to be cautious and overly reliant on others for guidance and approval, rather than acting impulsively on their own.

D. Submissive: Submissiveness is a hallmark of dependent personality disorder. Clients demonstrate extreme dependency on others for emotional and decision-making support, often avoiding disagreement and putting others' needs above their own to maintain relationships and avoid abandonment.

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Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is "{\"xRanges\":[111.828125,122.828125],\"yRanges\":[106.5,117.5]}"

Explanation

A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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