The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

Diaphoresis, piloerection, tremors, irritability, insomnia, nausea, and vomiting.

Diaphoresis, hypertension, hand tremors, hallucination/illusions, and potential seizures.

Cravings, depression, fatigue, hypersomnolence, and impaired judgment.

Heightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks.

Answer and Explanation

The Correct Answer is A

A) Correct. These symptoms are indicative of opioid withdrawal. Opioid withdrawal symptoms include sweating (diaphoresis), goosebumps (piloerection), tremors, irritability, insomnia, and gastrointestinal symptoms like nausea and vomiting.

B) Incorrect. These symptoms are more indicative of withdrawal from substances like alcohol or benzodiazepines, rather than opioids.

C) Incorrect. These symptoms are not specific to opioid withdrawal and may be seen in various conditions.

D) Incorrect. This cluster of symptoms is not characteristic of opioid withdrawal.

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Correct Answer is B

Explanation

A. Wernicke encephalopathy is caused by thiamine (Vitamin B1) deficiency, but it is not characterized by thiamine deficiency itself.
B. Wernicke encephalopathy is characterized by lesions in the hypothalamus and mammillary bodies in the brain.
C. While cognitive impairment may be present, this is not the primary characteristic of Wernicke encephalopathy.
D. Double vision and rapid eye movement are symptoms of Wernicke encephalopathy, but they are not the irreversible complication itself.

A. "Maybe it's just caused by aging. This usually happens at his age." B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." C. "Dad just didn't seem to know what he was doing. He has been forgetful for years." D. "Dad has always been so independent. He's lived alone for years since Mom died."

Correct Answer is B

Explanation

A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.

B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.

C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.

D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.

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The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

Correct Answer is B

Explanation

An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

Correct Answer is B

Explanation

A physician has prescribed an antidepressant medication for a 15yearold client. Which statement would be appropriate for inclusion in medication teaching?

Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

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