A nurse is collecting data from a client who has substance use disorder and reports recently taking opioids.
Which of the following findings should the nurse identify as a manifestation of opioid intoxication?
Tachycardia
Mental alertness
Hyperreflexia
Pinpoint pupils
The Correct Answer is D
d. Pinpoint pupils.
Explanation:
Opioid intoxication is characterized by various signs and symptoms, including central nervous system depression. One common manifestation of opioid intoxication is pinpoint pupils (miosis), which is caused by the effect of opioids on the pupillary constrictor muscles. The pupils become constricted and appear as small dots, hence the term "pinpoint."
The other options are not typical manifestations of opioid intoxication. Tachycardia (rapid heart rate) is more commonly associated with stimulant use rather than opioids. Mental alertness is typically reduced in cases of opioid intoxication, as opioids cause sedation and CNS depression. Hyperreflexia (exaggerated reflexes) is not a typical finding in opioid intoxication; instead, it may occur in withdrawal from certain substances such as alcohol or benzodiazepines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.
a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.
c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.
d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.
Correct Answer is C
Explanation
c. The bedroom extension cord is placed under a heavy nightstand.
The nurse should intervene and address the placement of the bedroom extension cord under a heavy nightstand. This poses a safety hazard as it increases the risk of electrical fire or tripping. The nurse shouldmeducate the client about the importance of using proper outlets and avoiding the use of extension cords in general, especially when they are hidden under heavy furniture.
Options a, b, and d do not require immediate intervention by the nurse:
a. The television set turned to a loud volume can be addressed by educating the client about the potential risks of prolonged exposure to loud noises and providing guidance on appropriate volume levels.
b. The presence of low chairs with no armrests in the dining room may not necessarily require immediate intervention unless there are specific safety concerns related to the client's mobility or balance. The nurse may provide general recommendations for safer seating options, especially if the client is at risk of falls or has difficulty getting up from low chairs.
d. The presence of wall-to-wall carpeting in the living room is a common feature in many homes and does not necessarily pose a safety hazard. However, the nurse may discuss general home safety measures, such as keeping the carpet clean and free of tripping hazards, especially for clients with mobility issues.
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