A nurse is assisting with the care of a client who last used heroin 8 hr ago. Which of the following findings should the nurse identify as a manifestation of opioid withdrawal?
Tachycardia
Miosis
Hypotension
Sedation
The Correct Answer is A
A. Tachycardia: Tachycardia, or an increased heart rate, is a common manifestation of opioid withdrawal. Withdrawal stimulates the sympathetic nervous system, leading to symptoms like tachycardia, sweating, anxiety, and restlessness.
B. Miosis: Miosis, or pinpoint pupils, is associated with opioid intoxication, not withdrawal. During withdrawal, pupils are often dilated (mydriasis) rather than constricted.
C. Hypotension: Hypertension, not hypotension, is more commonly seen during opioid withdrawal due to increased sympathetic nervous system activity. Blood pressure tends to rise rather than fall during withdrawal episodes.
D. Sedation: Sedation is a sign of opioid intoxication rather than withdrawal. Clients experiencing withdrawal are more likely to display agitation, irritability, and insomnia rather than drowsiness or sedation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
- "Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
- "Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
- "Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
- "You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
- "You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.
Correct Answer is D
Explanation
A. Promote bonding by encouraging the guardians to formula feed their newborn: Bonding occurs through close physical contact, responsiveness, and nurturing care, regardless of the feeding method. Bonding is important regardless of feeding method, but feeding choice should be based on the guardians’ preference, not directed solely by the nurse. Formula feeding is not necessary for promoting bonding.
B. Encourage guardians to allow relatives to provide the majority of the care for their newborn: Guardians should be encouraged to provide the majority of the newborn's care themselves to strengthen attachment and build confidence in their parenting abilities.
C. Ensure guardians know that criticism of newborn care is acceptable: Criticism can undermine the guardians' confidence and create stress. Support and positive reinforcement are important for helping new parents feel secure in their roles.
D. Inform guardians how to respond to their newborn's cues: Teaching guardians how to recognize and respond to their newborn's cues, such as hunger, discomfort, or need for interaction, promotes bonding, supports emotional development, and strengthens the parent-newborn relationship.
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