A nurse is making a follow-up call to a client who has a new prescription for an ACE Inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

The client likely suffered from intoxication as evidenced by hypokinesia.

Intoxication from substances such as opioids can lead to a range of symptoms including sedation and altered mental status. In this case, the presence of a needle in the antecubital space and the administration of naloxone suggest opioid use.

Hypokinesia, characterized by reduced movement, aligns with the symptoms observed in opioid intoxication, such as decreased responsiveness and drowsiness. The historical pattern of sedation, miosis (constricted pupils), and mood alteration further supports the diagnosis of intoxication as the underlying condition.

A.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

B.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

D.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

E.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

F.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

G.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

H.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

I.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.