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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Take vital signs on clients as they are admitted: Taking vital signs is within the scope of practice for assistive personnel (AP) and is an essential task during a mass casualty event. It provides critical baseline information that the licensed staff can use to prioritize care and identify urgent needs.
B. Respond to family members about a client's condition: Communicating about a client's medical condition requires clinical judgment and is the responsibility of licensed nursing staff or healthcare providers. APs are not trained or authorized to give out clinical information to family members.
C. Clean and dress client abdominal wounds: Wound care, especially for open or surgical wounds like those on the abdomen, involves assessment and sterile technique, which must be performed by licensed personnel, not assistive personnel.
D. Determine which clients should be seen first: Determining client priority, also known as triage, requires nursing knowledge, critical thinking, and clinical assessment skills. It is a responsibility that falls to licensed nurses, not assistive personnel.
Correct Answer is A
Explanation
A. Apply the gown before the gloves: The gown must be applied before donning gloves to ensure that the gown fully covers the arms and torso, providing a protective barrier against contamination. Gloves are then pulled over the gown cuffs to maintain a proper seal and reduce the risk of pathogen exposure, especially with infections like Clostridium difficile.
B. The gown with the gloves on: Wearing the gown after gloves compromises the sterile barrier, allowing pathogens to contact the skin or clothing. This technique increases the risk of contamination because the gloves may not completely cover or seal the gown’s cuffs properly, which is critical in preventing the spread of infection.
C. Tuck the glove cuffs under the gown sleeves: Gloves should not be tucked under gown sleeves. Instead, gloves should cover the gown cuffs, creating a continuous protective layer. Tucking gloves under the gown can leave the wrists exposed and vulnerable to contamination, particularly when caring for clients with highly transmissible infections.
D. Push the gown sleeves up to the elbows: Pushing the sleeves up to the elbows defeats the protective purpose of the gown. It exposes the forearms to potential pathogens and bodily fluids, increasing the risk of infection transmission to both the nurse and other clients, especially when dealing with spore-forming bacteria like Clostridium difficile.
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