A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?

Elevated heart rate

Hypertension

Pupilary dution

Tachypnea

Answer and Explanation

The Correct Answer is C

A. Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia.

B. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation.

C. Pupillary constriction (miosis).
Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness.

D. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.

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Correct Answer is C

Explanation

A. Planning with the client for how he can better handle frustration (option A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.

B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.

C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.

D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.

A. History of kidney disease B. When the client last drank alcohol C. If the client has taken disulfiram before D. History of liver disease

Correct Answer is D

Explanation

A. History of kidney disease is not as critical for disulfiram administration. The primary concern is related to hepatic metabolism.

B. When the client last drank alcohol is relevant information, but it is not the most critical factor to consider before administering disulfiram. The primary mechanism of disulfiram is to inhibit the breakdown of acetaldehyde, leading to an unpleasant reaction if alcohol is consumed, regardless of when the client last drank.

C. Whether the client has taken disulfiram before is important information, but it does not take precedence over the assessment of liver function. The history of liver disease is more directly related to the potential risks and adverse effects associated with disulfiram use.

D. History of liver disease is crucial to assess before administering disulfiram because disulfiram is metabolized in the liver. Patients with a history of liver disease may have impaired liver function, and the medication may not be well-tolerated or could exacerbate existing liver issues.

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A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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