A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?

Choice A reason: Immediate intubation is premature without first reversing opioid-induced respiratory depression with naloxone. Morphine’s rapid onset of lethargy and shallow breathing (7 breaths/min) indicates overdose, reversible by naloxone. Intubation is invasive and reserved for non-responsive cases, risking unnecessary complications when reversal is feasible, delaying targeted treatment in this acute scenario.

Choice B reason: Administering naloxone is the priority for opioid overdose, as evidenced by lethargy and respiratory depression (7 breaths/min) post-morphine. Naloxone, an opioid antagonist, rapidly reverses these life-threatening effects, restoring breathing and consciousness. Prompt administration is critical in older adults, who are more sensitive to opioids, ensuring patient safety and preventing hypoxia or death.

Choice C reason: Observing for opioid tolerance is inappropriate in this acute situation. Lethargy and shallow breathing indicate overdose, not tolerance, requiring immediate naloxone. Monitoring tolerance delays critical intervention, risking prolonged hypoxia, brain damage, or death, especially in an elderly patient with increased opioid sensitivity post-surgery, where respiratory depression is life-threatening.

Choice D reason: Assessing pain level is irrelevant when the patient exhibits opioid overdose symptoms like lethargy and respiratory depression. Pain assessment is secondary to reversing life-threatening respiratory compromise with naloxone. Delaying intervention for pain evaluation risks patient deterioration, as immediate action is needed to restore breathing and stabilize the patient post-morphine administration.

Choice A reason: Holistic care for chronic anxiety involves assessing how worry impacts physical, emotional, and social functioning. This approach considers the patient’s lifestyle, coping mechanisms, and overall well-being, fostering tailored interventions like cognitive-behavioral therapy or relaxation techniques. Understanding functional impairment ensures comprehensive care, addressing root causes and promoting long-term management of anxiety.

Choice B reason: Focusing on quick remedies prioritizes short-term symptom relief over holistic care. Chronic anxiety requires sustained strategies, like therapy or lifestyle changes, rather than temporary fixes like medication alone. This approach neglects emotional and social factors, limiting effectiveness and failing to address the multifaceted nature of the patient’s condition.

Choice C reason: Assuming the patient’s only goal is anxiety relief oversimplifies their needs. Holistic care recognizes diverse goals, such as improving relationships or daily functioning. This narrow focus ignores emotional, spiritual, or social aspects, reducing care quality and failing to align with the comprehensive, patient-centered approach required for chronic anxiety.

Choice D reason: Suggesting little hope for relief is counterproductive and dismissive. Holistic care empowers patients with hope through education, coping strategies, and support. This approach risks worsening anxiety by fostering despair, contradicting the nurse’s role in promoting resilience and well-being, and failing to address the patient’s potential for improvement.