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
dropdown
as evidenced by
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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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Correct Answer is A

Explanation

A. Cleanse skin eruptions with povidone-iodine. Cleaning the skin eruptions with a mild antiseptic like povidone-iodine can help reduce the risk of secondary bacterial infections and promote healing. Keeping the affected area clean is important in managing herpes simplex outbreaks.
B. Avoid over-the-counter topical ointments. Over-the-counter topical ointments are often recommended to help soothe the skin and alleviate discomfort during a herpes simplex outbreak. While some ointments may not be effective against the virus, it is not necessary to avoid all topical products.
C. Administer an antibiotic medication. Herpes simplex is caused by a virus, so antibiotics, which are effective against bacterial infections, would not be appropriate for treating this condition. Antiviral medications such as acyclovir or valacyclovir are indicated instead to help manage outbreaks.
D. Place disposable thermometers in the client's room. There is no specific need for disposable thermometers for a client with a herpes simplex outbreak. Standard infection control practices are sufficient, and there is no risk of contamination related to herpes that would require special thermometers.

A. Urine output B. Heart rate C. Sodium level D. Respiratory status E. Pain F. Serum amylase level G. Mental confusion H. Blood pressure I. Temperature J. Cold, clammy skin

Correct Answer is ["B","D","G","H","J"]

Explanation

Rationale for Correct Options:

Heart rate. The heart rate has increased from 90/min on Day 1 to 132/min on Day 2. This significant elevation is concerning for worsening systemic inflammation, hypovolemia, or sepsis and requires immediate intervention.
Respiratory status. The client initially had diminished breath sounds at the lung bases, but by Day 2, breath sounds are diminished throughout. This suggests worsening respiratory function, possibly due to acute respiratory distress syndrome (ARDS) or pleural effusion, both of which can complicate severe pancreatitis. Immediate assessment and intervention are necessary.
Mental confusion. The client was alert and oriented on Day 1 but is now disoriented to person, place, and time on Day 2. This change in mental status can indicate worsening systemic inflammation, sepsis, hypoxia, or metabolic disturbances such as hypocalcemia. Immediate evaluation is needed.
Blood pressure. While the client’s initial blood pressure was stable at 126/78 mm Hg, the current reading is not provided. If the client is experiencing hypotension, it could indicate worsening shock, requiring urgent intervention.
Temperature. The client’s temperature increased from 37.2 °C (99 °F) on Day 1 to 38.9 °C (102 °F) on Day 2. This suggests a developing infection, such as infected pancreatic necrosis or sepsis, which requires immediate reporting and further evaluation.
Cold, clammy skin. Cold, clammy skin is a sign of poor perfusion, which may indicate impending shock due to worsening sepsis or hypovolemia. This is an urgent finding requiring immediate attention.

Rationale for Incorrect Options:

Urine output. The client’s urine output was documented as 60 mL/hr, which is within the normal range. There is no indication of oliguria or anuria that would require immediate reporting.
Sodium level. The sodium level of 142 mEq/L is within the normal range and does not indicate a critical electrolyte imbalance requiring urgent intervention.
Pain. The client’s pain has increased from 8/10 to 10/10 despite receiving morphine via a PCA pump. While pain management is crucial, worsening pain alone is not the most urgent concern compared to systemic complications like respiratory failure or hemodynamic instability.
Serum amylase level. Although the serum amylase level is significantly elevated at 498 units/L, this is expected in acute pancreatitis and does not necessarily indicate an immediate life-threatening emergency. Trends in amylase and lipase levels are important for monitoring, but they do not require urgent reporting unless accompanied by other signs of deterioration.

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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 dropdownas evidenced bydropdown

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

Correct Answer is A

Explanation

A nurse is assisting in the care of a newly admitted client. Exhibits Which of the following findings should the nurse report immédiately to the provider?Select all that apply.

Correct Answer is ["B","D","G","H","J"]

Explanation

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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
dropdown
as evidenced by
dropdown