A nurse is assisting with the care of a client.

Select 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":"C","dropdown-group-2":"D"}

alcohol intoxication: Although the client consumed one beer, this small amount is unlikely to cause unresponsiveness, respiratory depression, or the need for naloxone administration. Alcohol intoxication alone does not explain the profound sedation and pinpoint pupils observed.
alcohol withdrawal: Alcohol withdrawal typically presents with signs like agitation, tremors, hallucinations, and seizures, not sedation, miosis, and depressed respiratory drive. The client’s symptoms are inconsistent with alcohol withdrawal.
hallucinogen intoxication: Hallucinogen use usually leads to agitation, paranoia, hallucinations, and dilated pupils (mydriasis), not the sedated state, respiratory depression, and miotic pupils that this client is exhibiting.
opioid intoxication: The client's unresponsiveness, respiratory depression, and pinpoint pupils, combined with a positive response to naloxone, are classic indicators of opioid intoxication. These findings directly align with the expected effects of opioid overdose.
opioid withdrawal: Opioid withdrawal presents with signs like agitation, mydriasis, diarrhea, piloerection, and flu-like symptoms. The client’s current state of sedation and miotic pupils contradicts what would be seen during opioid withdrawal.
amount of alcohol consumed: The small amount of alcohol (one beer) does not correlate with the severity of the client’s clinical presentation. Thus, alcohol consumption is not the primary factor contributing to the current state.
breath sounds: Breath sounds are clear and equal bilaterally, indicating that the lungs are not the source of the client's critical condition. There is no evidence of respiratory infection or pulmonary complications.
abdominal findings: Decreased bowel sounds are common in opioid intoxication due to decreased gastrointestinal motility. However, while supportive, this finding is less definitive than the hallmark sign of pupil constriction.
pupil characteristics: The presence of pinpoint pupils (miosis) is a hallmark sign of opioid intoxication. Miotic pupils, especially in an unresponsive client who improved after naloxone, strongly support opioid overdose as the primary diagnosis.
current temperature: The client's temperature is within normal limits, providing no significant diagnostic clue toward explaining the cause of unresponsiveness or respiratory depression.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

A. Decreased bowel sounds B. Urine output of 360 mL/12 hr C. Blood pressure of 100/74 mm Hg D. Distended neck veins

Correct Answer is D

Explanation

A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.

B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.

C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.

D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.

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A nurse is assisting with the care of a client. Select 1 condition and 1 finding to fill in each blank in the following sentence. The client likely suffered from _______ as evidenced by _______

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Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Vital Signs at 1000. For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume overload?

Correct Answer is D

Explanation

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A nurse is assisting with the care of a client.

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

The client likely suffered from
_
as evidenced by
_