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A nurse is assisting with the care of a client.

Exhibits

Drag 1 condition and 1 finding to fill in each blank in the following sentence.

The client likely suffered from 

as evidenced by
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Rationale:

  • Opioid intoxication. The client was found unresponsive with a needle in the left antecubital space, suggesting recent intravenous drug use. The administration of naloxone, an opioid antagonist, further supports opioid intoxication as the likely condition. Additionally, the client presents with decreased level of consciousness, respiratory depression (respiratory rate of 10/min), and decreased bowel sounds, all of which are classic signs of opioid intoxication.
  • Pupil characteristics
    The client’s pupils are miotic (constricted), which is a hallmark sign of opioid intoxication due to the drug’s effect on the parasympathetic nervous system. Opioids, particularly heroin and prescription narcotics, cause pinpoint pupils, which can help differentiate opioid intoxication from other conditions that may cause altered mental status.

Rationale for Incorrect Options:

  • Opioid withdrawal is characterized by symptoms such as agitation, dilated pupils, diarrhea, and tachycardia, none of which are present in this client. Instead, the client exhibits signs of central nervous system depression rather than hyperactivity, making withdrawal unlikely.
  • Hallucinogen intoxication typically presents with hallucinations, paranoia, agitation, and altered sensory perception. The client’s presentation does not include these findings, making hallucinogen intoxication an unlikely cause.
  • Alcohol intoxication is associated with slurred speech, ataxia, and confusion, but the client’s history indicates only one beer was consumed, which is not enough to cause such profound central nervous system depression. The presence of a needle and response to naloxone further support opioid intoxication rather than alcohol intoxication.
  • Alcohol withdrawal presents with symptoms such as tremors, tachycardia, hypertension, and agitation. The client is instead experiencing respiratory depression and sedation, which are inconsistent with alcohol withdrawal.


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Related Questions

Correct Answer is D

Explanation

A. Drain the tub water before the client gets out. Draining the tub water before the client gets out is not a recommended practice. Instead, the nurse should ensure that the client has a safe way to exit the tub while the water is still in it, as the water can provide support and stability when getting out.
B. Add bath oil to the water after the client gets into the tub. Adding bath oil to the water can create a slippery surface, increasing the risk of falls and injury. It is best to avoid bath oils, especially for clients who may have mobility issues or are at risk for falls.
C. Allow the client to remain in the bath for 30 min. While soaking in a tub can be relaxing, staying in the bath for too long can increase the risk of overheating or dehydration. A shorter duration may be more appropriate, depending on the client's condition and safety.
D. Check on the client every 10 min during the bath. Checking on the client regularly during the bath is essential for ensuring their safety. This practice allows the nurse to monitor for any signs of distress, difficulty, or the need for assistance, providing reassurance and promoting the client's well-being.

Correct Answer is D

Explanation

A. Administer a calcium channel blocker. Calcium channel blockers are used primarily for hypertension, angina, and certain cardiac conditions. They are not standard treatment for hyperemesis gravidarum, which is managed with fluid replacement, antiemetics, and nutritional support to prevent dehydration and electrolyte imbalances.
B. Encourage foods that are low in proteins. Protein intake is essential for fetal growth and maternal health. Clients with hyperemesis gravidarum may tolerate small, frequent meals with bland, high-protein foods better than low-protein options. Avoiding protein is not a recommended intervention, as it does not reduce nausea and may contribute to nutritional deficiencies.
C. Monitor for glycosuria. While glycosuria can occur during pregnancy, it is more relevant in the assessment of gestational diabetes rather than hyperemesis gravidarum. The primary concern in hyperemesis gravidarum is dehydration and electrolyte imbalances rather than glycosuria.
D. Monitor IV fluid therapy. Clients with hyperemesis gravidarum often experience severe nausea and vomiting, leading to dehydration and electrolyte imbalances. IV fluid therapy is a critical intervention to restore hydration, correct electrolyte imbalances, and prevent complications such as ketonuria and hypotension.

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