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 C
Explanation
c. Dispose of the used needle immediately in a sharps container.
The nurse should dispose of the used needle immediately in a sharps container to reduce the risk of a needlestick injury. Sharps containers are specifically designed for the safe disposal of needles and other sharp objects. By placing the used needle directly into a sharps container, the nurse eliminates the need for handling or manipulating the needle further, reducing the risk of accidental needlestick injuries.
Explanation for the other options:
a. Place a cap holder securely on the used needle before disposal: Cap holders are not recommended for securing used needles before disposal. They may not provide adequate protection against needlestick injuries and can potentially increase the risk of accidental needlesticks when atempting to secure the cap holder.
b. Recap the needle for disposal later: Recapping the needle increases the risk of a needlestick injury. It is generally not recommended to recap needles after use, as it poses a greater risk of accidental puncture.
d. Detach the used needle and dispose of it promptly: Detaching the needle from the syringe before disposal is not recommended, as it increases the risk of a needlestick injury. It is safer to dispose of the needle and syringe as a unit in a sharps container to minimize the risk of accidental puncture.
Correct Answer is B
Explanation
The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.
a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.
c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.
d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.
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