A hospice nurse is visiting with the son of a client who has terminal cancer.
The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?

Choice A rationale:

Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.

Choice B rationale:

Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.

Choice C rationale:

Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.

Choice D rationale:

Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.

The correct answer is A. Increased pain.

Choice A reason: Naloxone is an opioid antagonist that, when administered, reverses the effects of opioids. Since opioids provide analgesia, their reversal will lead to the return of pain sensation. The normal pain response varies widely among individuals and depends on the type and amount of opioid the patient received, as well as their pain threshold and tolerance.

Choice B reason: Somnolence, or drowsiness, is a common effect of opioid administration. Naloxone works by displacing opioids from their receptors, which should counteract the sedative effects of opioids and reduce somnolence. Therefore, after naloxone administration, the nurse should not expect somnolence as a finding.

Choice C reason: Hyperglycemia, or high blood sugar, is not a direct effect of naloxone administration. While some studies suggest that naloxone may affect blood glucose levels under certain conditions, such as in the case of tramadol overdose, it does not typically cause hyperglycemia. Normal blood glucose levels range from 70 to 99 mg/dL fasting, and up to 140 mg/dL two hours after eating.

Choice D reason: Hypoventilation, or reduced breathing rate and depth, is caused by opioid administration. Naloxone’s role is to reverse this effect, restoring normal breathing rates. The normal respiratory rate for a healthy adult at rest is 12 to 20 breaths per minute.