A nurse is assisting with the care of client.
Drag 1 condition and 1 finding to fill in each blank in the following sentences
The client likely suffered from
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Condition: Opioid intoxication – The client's presentation of unresponsiveness, respiratory depression (RR 10/min), and miosis (pinpoint pupils) is consistent with opioid intoxication. Additionally, the presence of a needle in the antecubital space suggests recent intravenous drug use.
Finding: Pupil characteristics – Opioid intoxication commonly causes miosis (pinpoint pupils), which was observed in the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Encourage the client to use overbed trapeze:
Encouraging the client to use an overbed trapeze is an appropriate intervention to promote independence and mobility after an above-the-knee amputation. The trapeze allows the client to move, reposition themselves, and perform activities of daily living more independently, which is important for regaining strength and confidence during the rehabilitation process. It aids in improving upper body strength and assists in early mobility efforts.
B) Maintain abduction of the client's residual limb with a pillow:
Placing a pillow under the residual limb in a position that maintains abduction (separation of the residual limb away from the body) is not recommended after an above-the-knee amputation. This position can lead to contractures of the hip joint, limiting mobility and the ability to use a prosthetic limb in the future. Proper positioning usually involves keeping the residual limb flat or neutral to avoid deformities.
C) Caution the client to avoid a prone position while in bed:
This recommendation is incorrect. In fact, encouraging the client to spend time in the prone position (lying on their stomach) can help prevent hip contractures, especially after an above-the-knee amputation. It is important for the client to position their body in ways that encourage proper limb alignment and prevent long-term complications such as contractures that could impede mobility.
D) Keep a loose, absorbent dressing over the client's surgical site:
A loose, absorbent dressing is not ideal for post-surgical care following an amputation. A dressing should be secure, sterile, and changed regularly to prevent infection and promote optimal wound healing. Keeping a dressing loose could lead to the risk of infection or delayed healing. The nurse should follow the provider’s orders for dressing changes and monitor for signs of infection.
Correct Answer is D
Explanation
A) Steatotic liver disease: Steatotic liver disease, or fatty liver disease, is typically associated with excess fat in the liver, often linked to alcohol use, obesity, or diabetes. While it can affect liver function, it is not primarily associated with deficiencies in iron and vitamin B12. Therefore, this condition is not directly related to the lab findings of low iron and vitamin B12.
B) Leukemia: Leukemia is a type of cancer that affects the blood and bone marrow, leading to abnormal white blood cell production. While leukemia can cause anemia as a secondary effect due to bone marrow dysfunction, it is not typically characterized by deficiencies in both iron and vitamin B12 simultaneously. The lab findings are more consistent with a nutritional or absorption issue rather than leukemia.
C) Hepatitis: Hepatitis refers to inflammation of the liver, usually caused by a viral infection or other factors. While hepatitis can lead to various blood abnormalities, it is not specifically linked to both iron and vitamin B12 deficiencies. Hepatitis more commonly affects liver function and may cause jaundice, but it does not directly explain low iron and B12 levels.
D) Anemia: Both iron and vitamin B12 are essential for the production of healthy red blood cells. Iron deficiency can lead to iron-deficiency anemia, and vitamin B12 deficiency can cause pernicious anemia. Therefore, low levels of both iron and vitamin B12 suggest the possibility of anemia, and the nurse should monitor the client for signs and symptoms of this condition, such as fatigue, pallor, and weakness.
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