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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   
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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Related Questions

Correct Answer is ["C","D","E"]

Explanation

A. "The client in room 204 received some pain medicine earlier today": This statement is vague and nonspecific, lacking essential information such as the type of pain medication, dose, timing, and client response. Change-of-shift reports require clear, detailed, and actionable information to ensure continuity of care.

B. "The client in room 205 has had several visitors today": Information about visitors is generally not relevant to clinical care unless it impacts the client's condition. Reporting should focus on clinical updates, treatments, medications, or changes in the client’s status that require attention from the incoming nurse.

C. "The client in room 204 has a new prescription for gentamicin": This statement provides important clinical information regarding a change in the medication regimen. It alerts the next nurse to monitor for potential side effects, such as nephrotoxicity or ototoxicity, associated with gentamicin use.

D. "The client in room 203 will undergo surgery at 0900 tomorrow": Communicating scheduled surgeries is critical for planning preoperative care, ensuring that preoperative checklists are completed, and managing fasting requirements. It allows the next shift to prepare the client properly and coordinate care.

E. "The client in room 205 is scheduled for a dressing change at 1800": Including scheduled treatments like dressing changes ensures that important interventions are completed on time. It also helps the incoming nurse prioritize tasks and manage the shift effectively to meet the client’s care needs.

Correct Answer is D

Explanation

A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.": Congenital dermal melanocytosis, also known as Mongolian spots, are harmless pigmented birthmarks and are unrelated to bilirubin levels or jaundice risk in newborns.

B. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding itself is not a reason to stop or supplement with formula unless medically necessary. Breastfeeding jaundice can occur, but proper feeding techniques and frequency usually manage it without needing supplementation.

C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements actually help lower bilirubin levels by aiding in the excretion of bilirubin through stool, so this would not increase jaundice risk.

D. "This is because your baby's liver is not yet efficient at breaking down red blood cells.": Newborns often experience physiological jaundice because their immature livers cannot efficiently process the breakdown products of red blood cells, leading to elevated bilirubin levels in the blood.

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