A nurse is caring for a client who is prescribed extended-release Morphine. The nurse should recognize which of the following assessment cues as an indication of opioid overdose?

Increased heart rate

Slow, shallow breathing

Constricted pupils

Increased motor activity

Answer and Explanation

The Correct Answer is B

Choice A reason:
Increased heart rate is not typically a sign of opioid overdose. Opioid overdose often leads to a decrease in the body's autonomic responses, which can cause a slowing of the heart rate rather than an increase.

Choice B reason:
Slow, shallow breathing is a hallmark sign of opioid overdose. Opioids can depress the central nervous system, leading to respiratory depression. This is a critical symptom and requires immediate medical attention¹²³⁴.

Choice C reason:
Constricted pupils, also known as pinpoint pupils, are another classic sign of opioid overdose. This occurs due to the action of opioids on the part of the brain that regulates the size of the pupils¹²³⁴.

Choice D reason:
Increased motor activity is generally not associated with opioid overdose. Instead, opioids tend to cause a decrease in motor activity, leading to lethargy and a lack of coordination.

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Correct Answer is B

Explanation

Choice A reason:
The statement "Alcohol tolerance causes me to have an increased effect when taking opiates" is incorrect. Alcohol tolerance refers to the body's diminished response to the effects of alcohol due to prolonged exposure. It does not directly affect the body's response to other substances like opiates. However, it's important to note that mixing alcohol with opiates can be dangerous and is generally advised against due to the risk of respiratory depression and other adverse effects.

Choice B reason:
The statement "I will develop a decreased physical response to alcohol" is correct and indicates effective teaching. As a person develops alcohol tolerance, their body requires more alcohol to achieve the same effects that were previously attained with less alcohol. This is due to physiological adaptations within the body, particularly in the liver and central nervous system, which become more efficient at metabolizing alcohol and less responsive to its effects.

Choice C reason:
The statement "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal" is incorrect. Alcohol tolerance itself is not a medical emergency; rather, it is a physiological adaptation to regular alcohol consumption. Withdrawal, on the other hand, can be a medical emergency if severe symptoms such as seizures or delirium tremens occur. Tolerance and withdrawal are related but distinct phenomena; tolerance can lead to dependence, which, when alcohol use is stopped, can result in withdrawal symptoms.

Choice D reason:
The statement "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol" is misleading. Alcohol tolerance does not produce physical changes in the absence of alcohol. Instead, tolerance is characterized by a reduced response to alcohol when it is consumed. Physical changes, such as withdrawal symptoms, may occur when a person who has developed tolerance stops consuming alcohol, but these are not due to tolerance itself.

A. Refer the client to a mental health care provider for evaluation and treatment. B. Determine the presence and degree of suicidal risk. C. Identify support groups in the community for long-term treatment. D. Assist the client to identify negative effects of chemical dependency.

Correct Answer is B

Explanation

Choice A reason:
Referring the client to a mental health care provider is an important step, but it may not be the immediate priority. The referral process can be initiated once the client's immediate safety and acute needs are addressed.

Choice B reason:
Determining the presence and degree of suicidal risk is the priority nursing intervention. Clients with depressive disorders, especially those experiencing significant life stressors such as job loss and undergoing alcohol withdrawal, are at a higher risk for suicide. It is crucial to assess their risk and take appropriate measures to ensure their safety.

Choice C reason:
Identifying support groups is a valuable part of long-term treatment and recovery, but it is not the immediate priority. Support groups can provide ongoing assistance and a sense of community once the client is stable and ready to engage in long-term recovery.

Choice D reason:
Assisting the client to identify the negative effects of chemical dependency is an important aspect of treatment, but it is not the immediate priority. This intervention is part of the client's long-term recovery and education process.

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A nurse is caring for a client who is prescribed extended-release Morphine. The nurse should recognize which of the following assessment cues as an indication of opioid overdose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates that the teaching was effective?

Correct Answer is B

Explanation

A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Correct Answer is B

Explanation

A client presents with symptoms consistent with factitious disorder. Which of the following hypotheses should the nurse prioritize in the care of this client? (Select all that apply)

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

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A nurse is preparing to teach a client about the lithium prescription for treating bipolar disorder. Which of the following statements should the nurse include in the teaching?

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