Review Practice Exercise 5

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Practice Exercise 5

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Total Questions : 5

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Question 1:

The nurse is admitting a client who injects opioids and has a temperature of 38.9°C (102°F), a new murmur, and pleuritic chest pain. Which of the following assessments should the nurse prioritize?

A. Inspection of the extremities for Janeway lesions and splinter hemorrhages. B. Auscultation of respiratory rate, effort, and oxygen saturation. C. Documentation of the client's substance use history and last dose taken. D. Measurement of the client's Clinical Opiate Withdrawal Scale score.

Answer and Explanation

Choice A:

Dermatological manifestations like Janeway lesions provide supporting diagnostic evidence for systemic infection. These peripheral findings do not indicate immediate life-threatening physiological instability. Auscultating breath sounds takes precedence over skin inspection. Clinicians assess cutaneous signs only after establishing stable vital signs.

Choice B:

Respiratory assessment remains the critical immediate priority during acute clinical deterioration. Pleuritic pain strongly indicates pulmonary embolization originating from infected cardiac vegetations. Evaluating baseline oxygenation parameters identifies early gas exchange impairments. Prompt detection prevents fatal respiratory collapse.

Choice C:

Substance use history is essential for comprehensive admission documentation and nursing planning. Obtaining a detailed timeline does not address acute cardiopulmonary compromise. Emergency physiological evaluation supersedes chronic history taking. Nurses prioritize active symptom management over administrative data collection.

Choice D:

Withdrawal scoring using the Clinical Opiate Withdrawal Scale evaluates physical dependence severity. A client presenting with high fever and new murmurs faces immediate infectious risks. Assessing acute infection complications supersedes routine substance withdrawal monitoring. Stabilization of vital organ function remains paramount during sepsis evaluations.

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Question 2:

The nurse is caring for a client at 32 weeks of gestation who is on methadone maintenance and reports early morning sweating, nausea, and restlessness. Which of the following actions should the nurse anticipate?

A. Tapering the methadone dose gradually to protect the fetus from withdrawal at delivery. B. Discontinuing methadone and transitioning the client to extended-release naltrexone. C. Increasing the dose or dividing it into twice-daily administration. D. Administering naloxone in a small titrated dose to confirm the client's dependence.

Answer and Explanation

Choice A:

Tapering methadone during pregnancy is strictly contraindicated due to high risks of precipitating fetal demise or triggering preterm labor. Abrupt withdrawal causes uterine hypertonicity, severe fetal hypoxia, and increased risk of maternal relapse to illicit substances. Dosing must remain sufficient to prevent maternal withdrawal symptoms entirely during all gestational stages. Protecting fetal physiology requires maintaining adequate opioid agonist coverage.

Choice B:

Discontinuing methadone and initiating naltrexone induces severe acute withdrawal that threatens pregnancy viability. Full opioid antagonists strip mu receptors, causing catastrophic uteroplacental insufficiency and elevated fetal mortality. Naltrexone maintenance is never initiated during active pregnancy for clients already stabilized on full agonists. Maintaining opioid agonist therapy remains the standard of care for pregnant individuals.

Choice C:

Pregnancy increases methadone clearance, leading to subtherapeutic trough levels and early morning withdrawal symptoms. Increasing the total daily dose or transitioning to a divided dose schedule stabilizes plasma drug concentrations throughout 24 hours. Split dosing prevents peak-related sedation while eliminating trough withdrawal during peak fetal developmental windows. This adjustment maintains steady maternal blood levels and protects fetal well-being.

Choice D:

Administering naloxone during pregnancy is dangerous because competitive antagonist action precipitates sudden fetal withdrawal and placental dysfunction. Diagnostic challenge tests using antagonists are contraindicated due to the extreme risk of spontaneous abortion or fetal death. Clinical signs of sweating and restlessness sufficiently confirm inadequate dosing without invasive diagnostic testing. Safe management relies on symptom-based dose adjustments.

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Question 3:

The nurse is documenting care for a client with opioid use disorder. Which of the following entries reflect appropriate documentation practice? Select all that apply.

A. "Urine toxicology positive for fentanyl; results reviewed with client." B. "Respiratory rate 10 breaths/min at 0800; scheduled dose held, primary health care provider notified." C. "Client is drug seeking and manipulative with staff throughout the shift." D. "Clinical Opiate Withdrawal Scale score 14 at 1400; clonidine administered per prescription." E. "Client admits to being a longtime addict with a dirty urine screen."

Answer and Explanation

Choice A:

Documenting specific diagnostic laboratory findings provides factual objectivity without embedding subjective assumptions or clinical bias. Reviewing findings directly with the client promotes patient-centered communication and therapeutic engagement. This entry accurately records objective clinical data and nursing actions. Legal documentation standards require precise reporting of diagnostic results.

Choice B:

Recording specific physiological parameters alongside precise time stamps ensures clinical accuracy during acute pharmacological titration. Explicitly documenting held medications and provider communication establishes clear accountability protocols for patient safety. Objective metrics prevent dangerous misunderstandings among interprofessional care teams. Factual recording of respiratory depression guides timely medical interventions.

Choice C:

Categorizing client behaviors as manipulative introduces pejorative bias that compromises medical objectivity in health records. Subjective descriptors lack concrete observational data required to support clinical nursing assessments. Stigmatizing entries degrade interprofessional care quality and perpetuate healthcare disparities. Nurses must record specific observable actions rather than personal opinions.

Choice D:

Utilizing validated clinical evaluation scales provides quantifiable measurement of physical withdrawal severity at specific intervals. Documenting the corresponding pharmacotherapy administration demonstrates evidence-based intervention aligned with prescribed protocols. Objective scoring minimizes individual interpreter variance across nursing shifts. Precise tracking supports optimal symptom management and dosing adjustments.

Choice E:

Employing outdated terminology like addict and dirty urine reinforces person-stigmatizing language within official health documentation. Modern clinical practice mandates objective terms such as positive toxicology or individual with substance use disorder to preserve professional neutrality. Judgmental phrasing damages the therapeutic relationship and invalidates client care records. Documentation must reflect professional, non-judgmental medical terminology.

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Question 4:

The nurse is planning care for a client admitted after a third overdose in 6 months who states, "There is no point in trying anymore." Which of the following nursing diagnoses should the nurse identify as the priority?

A. Risk for suicide related to hopelessness and repeated overdose. B. Ineffective coping related to reliance on substances for stress regulation. C. Chronic low self-esteem related to internalized stigma and repeated relapse. D. Deficient knowledge related to loss of tolerance and overdose risk.

Answer and Explanation

Choice A:

The client demonstrates profound hopelessness and recurrent life-threatening behaviors indicating imminent suicide risk. Safety and life preservation represent the absolute highest nursing priority according to physiological and safety hierarchies. Immediate suicide precautions must be implemented to prevent potential self-directed violence. Addressing immediate safety precedes secondary cognitive or behavioral nursing care planning.

Choice B:

Ineffective coping addresses impaired adaptive abilities and reliance on maladaptive stress regulation mechanisms. While substance use reflects underlying coping deficits, this diagnosis does not address immediate life-threatening safety threats. Psychosocial rehabilitation becomes the focus only after establishing complete physical safety and mitigating active self-harm intention. Prioritizing coping strategies prematurely delays urgent safety measures and crisis intervention.

Choice C:

Chronic low self-esteem evaluates negative self-evaluations stemming from internalized stigma and recurrent relapse cycles. Evaluating self-worth is a long-term goal that does not mitigate the immediate risk of fatal self-harm. Long-term self-concept interventions are secondary to immediate mortality reduction and safety monitoring. The nurse must first secure physical safety before addressing long-standing psychological perceptions.

Choice D:

Deficient knowledge regarding overdose risk and lost tolerance represents an essential educational nursing need. Educational deficits are non-emergent and cannot be addressed while the client experiences severe active despair. Patient teaching requires cognitive readiness that is absent during acute psychological crisis and suicidal ideation. Client survival and safety override all patient education goals during emergent admissions.

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Question 5:

The nurse is coordinating postoperative pain management for a client maintained on buprenorphine who has just undergone an open reduction of a femoral fracture. Which of the following actions should the nurse take? Select all that apply.

A. Ensure the client's maintenance buprenorphine is continued as part of the plan of care. B. Request a prescription for nalbuphine, as it provides analgesia without disrupting maintenance therapy. C. Advocate for multimodal analgesia with additional short-acting agents titrated to effect. D. Withhold all opioid analgesia and offer nonpharmacologic comfort measures only. E. Explain to the client that the maintenance dose itself will control the surgical pain.

Answer and Explanation

Choice A:

Continuing maintenance buprenorphine prevents acute withdrawal syndrome and maintains baseline stability during severe surgical stress. Discontinuing baseline therapy destabilizes addiction recovery and increases the risk of postoperative relapse. The maintenance dose provides background tolerance management while acute pain is treated separately. Preserving therapy maintains essential neurobiological stability and long-term treatment retention.

Choice B:

Administering mixed agonist-antagonists like nalbuphine triggers precipitated withdrawal by displacing buprenorphine from mu-opioid receptors. Mixed agents compete unpredictably at receptor sites and fail to provide effective relief for acute severe pain. Introducing partial or mixed agents creates severe physiological instability during acute surgical recovery. The nurse must avoid agonist-antagonist combinations to prevent acute neurological distress.

Choice C:

Managing severe orthopedic pain requires multimodal analgesia combining non-opioids with short-acting full opioid agonists titrated to effect. High-affinity short-acting opioids can overcome partial receptor blockade to treat breakthrough acute pain effectively. Non-opioid adjuncts target distinct pain pathways to reduce overall opioid requirements. Combining therapeutic modalities achieves adequate nociceptive control and improves patient postoperative recovery.

Choice D:

Withholding opioid analgesia for severe surgical trauma violates ethical pain management standards and causes unnecessary suffering. Buprenorphine baseline tolerance prevents non-opioid modalities alone from controlling acute severe fracture pain effectively. Uncontrolled pain triggers severe autonomic stress, delayed healing, and elevated risk of addiction relapse. Clients maintained on buprenorphine require adequate analgesia using titrated full agonists.

Choice E:

Explaining that maintenance doses control surgical pain provides inaccurate education regarding acute pain physiology and buprenorphine pharmacodynamics. Buprenorphine maintenance satisfies baseline opioid dependence but does not provide additional analgesia for acute tissue injury. Severe orthopedic trauma generates high-intensity nociceptive signaling requiring targeted supplemental analgesic agents. Nurses must acknowledge pain and advocate for supplemental analgesia to ensure effective relief.

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Practice Exercise 5

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