A nurse in a community clinic is assessing a client who reports injecting heroin 1 hr ago. Which of the following findings should the nurse expect?
Dilated pupils
Tachypnea
Euphoria
Nystagmus
The Correct Answer is A
Explanation: Heroin is a central nervous system depressant that can cause various physiological effects on the body. Dilated pupils are a common sign of heroin use, along with a decrease in blood pressure, respiratory rate, and heart rate. The pupils will appear larger than usual because heroin depresses the parasympathetic nervous system, which controls the size of the pupils.
Tachypnea, or rapid breathing, is not typically associated with heroin use, as it is a central nervous system depressant. Euphoria, or a feeling of intense pleasure or happiness, is a common effect of heroin use, but it is not the most reliable sign of heroin use, as other drugs can also produce this effect. Nystagmus, an involuntary movement of the eyes, is not a common sign of heroin use. Dilated pupils are a reliable sign of heroin use and should be documented in the client's medical record. It is important for the nurse to assess for other signs of drug use and to provide appropriate care and support to the client, which may include referrals for substance abuse treatment. The nurse should also follow agency policies and procedures for reporting drug use and abuse to appropriate authorities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. Herpes simplex.
Choice A rationale:
Diphtheria requires droplet precautions because it is primarily spread through respiratory droplets when an infected person coughs or sneezes.
Choice B rationale:
Herpes simplex requires contact precautions because it is spread through direct contact with infected lesions or body fluids.
Choice C rationale:
Pulmonary tuberculosis requires airborne precautions due to its transmission through airborne particles when an infected person coughs, sneezes, or talks.
Choice D rationale:
Pertussis, also known as whooping cough, requires droplet precautions as it spreads through respiratory droplets.
Correct Answer is C
Explanation
. Home safety measures are a priority for a client with alcohol use disorder and cirrhosis of the liver, as they may have mobility or balance issues that increase their risk of falls or injury. Assessing the client's home environment and identifying any potential hazards is crucial in preventing further injury or harm to the client. Once the home safety measures have been determined, the case manager can then arrange for a home health nurse to visit the client, provide information on self-help groups for alcohol use disorder, and contact a social worker to assist with managing finances.
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