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

Answer and Explanation

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.

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Correct Answer is ["A","B","C"]

Explanation

Frequent headaches: Phenelzine, an MAOI, can cause hypertensive crisis, with one of the earliest signs being persistent or worsening headaches. Frequent headaches must be treated as a possible warning of dangerously elevated blood pressure and require immediate provider notification.
Elevated blood pressure (169/91 mm Hg): The significant rise in the client's blood pressure compared to baseline indicates new-onset hypertension. This is a serious adverse effect associated with MAOIs and signals the potential development of a hypertensive crisis, which must be urgently addressed.
Difficulty sleeping: Difficulty sleeping or insomnia is a common side effect of phenelzine and other antidepressants. Although not life-threatening, insomnia can impair recovery if untreated and should be documented and discussed with the provider to adjust management if needed.
Feeling much better: Improvement in mood and reduced fatigue are intended therapeutic outcomes of phenelzine treatment. These findings are positive signs and do not indicate an adverse reaction that needs intervention.
Heart rate 78/min and respiratory rate 18/min: Both values are within normal ranges and do not suggest immediate concerns related to cardiovascular or respiratory function. They should continue to be monitored but do not require urgent action.

A. Oxygen saturation 95% B. Respiratory rate 14/min C. Urinary output 160 mL/8hr D. Blood pressure 108/58 mm Hg

Correct Answer is C

Explanation

A. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most clients and does not indicate respiratory compromise. No immediate provider notification is necessary based solely on this oxygen saturation level during opioid therapy.

B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is normal. Significant respiratory depression from opioids like hydromorphone would typically be indicated by a rate lower than 12 breaths per minute.

C. Urinary output 160 mL/8 hr: Urinary output should be at least 30 mL/hr. A total of 160 mL in 8 hours is significantly low, suggesting possible urinary retention or decreased renal perfusion, both of which can be side effects of opioid use and should be reported promptly.

D. Blood pressure 108/58 mm Hg: While this blood pressure is on the lower side, it is not critically low for many adults. Unless the client is symptomatic with dizziness or fainting, this blood pressure alone does not require immediate provider notification.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse is collecting data from a client who is receiving hydromorphone for pain management. For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

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