A nurse on an inpatient mental health unit is caring for a client.

Exhibits

Select 4 findings the nurse should identify as positive manifestations of the clients diagnosis

Rationale:

A. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing.

B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity.

C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression.

D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.

Rationale for correct choices:

• Opioid intoxication: The client shows hallmark signs of opioid overdose, including respiratory depression, bradycardia, hypotension, miosis (pupillary constriction), confusion, and hypothermia. A history of oxycodone use and psychosocial stressors support opioid misuse.
• Obtain prescription for naloxone: Naloxone is a competitive opioid antagonist that rapidly reverses the life-threatening effects of opioid toxicity, particularly respiratory depression and central nervous system suppression.
• Prepare to initiate mechanical ventilation: The client’s respiratory rate is critically low at 10 breaths/min with oxygen saturation at 90%. Mechanical ventilation may be necessary if the client cannot maintain adequate oxygenation even after naloxone administration.
• Respiratory rate: This is a key indicator of opioid intoxication severity and response to naloxone. Ongoing monitoring is essential to assess ventilation adequacy and detect recurrent respiratory depression.
• Pupillary reaction: Miosis is a key sign of opioid overdose, and pupil size can help gauge the severity of intoxication. As naloxone takes effect, pupils typically dilate, signaling reversal.

Rationale for incorrect choices:

• Alcohol intoxication: While the client has a history of alcohol use disorder, the physical findings (e.g., pinpoint pupils, bradycardia, low respiratory rate) are more consistent with opioid toxicity than ethanol intoxication.
• Stimulant intoxication: Stimulant overdose would present with hypertension, hyperthermia, tachycardia, and dilated pupils not the bradycardia, hypothermia, and miosis seen here.
• Opioid withdrawal: Opioid withdrawal typically presents with symptoms like dilated pupils, tachycardia, agitation, and diaphoresis—not CNS depression and hypoventilation.
• Obtain prescription for restraints: There is no evidence of violent or aggressive behavior requiring restraints; the client is sedated and obtunded, not agitated or combative.
• Collect a blood sample for ethanol level: This might be helpful later, but it does not take priority in a client presenting with acute signs of opioid overdose. Immediate interventions to support breathing are more urgent.
• Cardiac arrhythmias: Although bradycardia is present, continuous ECG monitoring may be useful, but arrhythmias are not the primary risk in opioid overdose compared to respiratory depression.
• Ethanol level: Alcohol toxicity is not the most likely cause here, so monitoring ethanol level will not help guide the immediate treatment and stabilization of this client.