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 A
Explanation
Explanation: The first action the parish nurse should take is to ask family members about the impact of the disease on relationships within the family. A diagnosis of heart disease can affect the client and the client's family emotionally, physically, and financially. By assessing the family's understanding of the disease, the nurse can identify their needs, concerns, and coping strategies. The nurse can also provide emotional support, education, and resources to help the family manage the disease and improve their quality of life. Offering to accompany the client and the client's partner during health care provider visits, assisting the client and the client's partner with finding an affordable exercise program, and discussing the benefits of eating a well-balanced diet with the client's family are appropriate actions that the nurse can take. However, these actions are not the priority until the nurse has assessed the family's understanding and need
Correct Answer is ["B","C","D"]
Explanation
The correct answers are B, C, and D. The nurse should assist the client in using guided imagery, maintain the head of the client's bed in an elevated position after eating, and provide sips of room-temperature ginger ale between meals. Guided imagery can help distract the client from the nausea and promote relaxation.
Elevating the head of the bed after eating can help prevent reflux and nausea. Ginger ale can help relieve nausea and can be sipped slowly between meals. Using seasonings to enhance the flavor of foods is not likely to help with chemotherapyinduced nausea, and cold milk as a meal replacement may not provide enough calories and nutrients.
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