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 C

Explanation

Choice A reason:
Escorting the client to the common area is not the priority action during a panic attack. The common area may have too much stimulation and could potentially worsen the client's anxiety. It is important to provide a quiet and safe environment for the client during a panic attack.

Choice B reason:
Contacting security for possible restraints is not the priority action and should only be considered if the client is a danger to themselves or others. Restraints can increase the client's anxiety and agitation, and the goal is to de-escalate the situation in a non-threatening manner.

Choice C reason:
Staying with the client is the priority action. The presence of a nurse can provide reassurance and a sense of safety. The nurse should use a calm and soothing voice, maintain a non-threatening posture, and stay with the client until the panic attack subsides. Offering support and using relaxation techniques can help the client regain control.

Choice D reason:
Staying away from the client is not the priority action. Isolation can increase the client's fear and anxiety. The nurse should remain with the client, offering reassurance and monitoring the client's condition throughout the panic attack.

A. Escort the client to the common area. B. Contact security for possible restraints. C. Stay with the client. D. Stay away from the client.

Correct Answer is C

Explanation

Choice A reason:
Escorting the client to the common area is not the priority action. While being around others can sometimes be comforting, during a panic attack, the client may feel overwhelmed and exposed, which could exacerbate the situation.

Choice B reason:
Contacting security for possible restraints should be a last resort and is not the priority action. Restraints can increase anxiety and fear, potentially escalating the panic attack. The use of restraints is only considered when the client is at risk of harming themselves or others and all other interventions have failed.

Choice C reason:
Staying with the client is the priority action. During a panic attack, the client needs reassurance and a sense of safety. The nurse's presence can provide comfort. The nurse should remain calm, use a quiet voice, and avoid making any sudden movements. Implementing relaxation techniques and promoting a calming environment are also beneficial.

Choice D reason:
Staying away from the client is not the priority action. Leaving the client alone can increase feelings of isolation and fear. The nurse should provide continuous observation and support during the panic attack.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

Correct Answer is C

Explanation

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

Correct Answer is C

Explanation

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