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A nurse is caring for a client in an emergency department.

The nurse reviews the medical record.

Complete the following sentence by using the lists of options.

The client likely experienced

as evidenced by  
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Rationale for correct choices:

  • Opioid intoxication: The client’s current presentation is classic for opioid overdose, which includes CNS depression (drowsy, difficult to arouse), respiratory depression (RR 10/min), hypotension, decreased bowel sounds, and history of IV drug use (needle mark). The administration of naloxone (an opioid antagonist) at the scene further strongly supports opioid toxicity as the cause.
  • Pupil characteristics: The most distinguishing clinical sign is miosis (pinpoint pupils), which is a hallmark of opioid intoxication. This helps differentiate it from other causes of altered mental status. In contrast, opioid withdrawal causes mydriasis (dilated pupils), which was seen in the client’s prior admission—highlighting the difference between intoxication vs withdrawal.

Rationale for incorrect choices:

  • Alcohol intoxication: Typically presents with slurred speech, ataxia, and CNS depression, but does not cause pinpoint pupils or respond to naloxone. Also, one beer is insufficient to explain severe respiratory depression.
  • Alcohol withdrawal: Would present with tachycardia, hypertension, tremors, agitation, diaphoresis, and possibly seizures, not sedation and respiratory depression.
  • Opioid withdrawal: Presents with the opposite findings—agitation, mydriasis, diarrhea, vomiting, diaphoresis, and piloerection (as seen in the prior record), not CNS depression.
  • Amount of alcohol consumed: One beer is not enough to cause the severity of symptoms seen.
  • Breath sounds: Lung sounds are clear and do not contribute to identifying the cause.
  • Current temperature: Temperature is within normal range and not diagnostic in this scenario.


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Related Questions

Correct Answer is D

Explanation

Rationale:
A. This statement describes acupressure or acupuncture principles, not biofeedback. Biofeedback does not involve physical stimulation of pressure points. Instead, it uses monitoring devices to provide real-time information about physiological functions so the client can learn to consciously control them.

B. This describes herbal or alternative pharmacologic therapy, not biofeedback. Biofeedback does not involve the use of herbs or any substances. It is a behavioral and mind-body technique that focuses on self-regulation of physiological processes.

C. This reflects concepts associated with massage therapy or practices like Reiki, which focus on manipulating soft tissue or energy flow. Biofeedback does not involve physical manipulation of tissues or energy flow theories.

D. Biofeedback works by using electronic monitoring devices to give the client feedback on physiological functions such as heart rate, muscle tension, or skin temperature. The client then uses relaxation techniques, breathing control, and focused concentration to consciously modify these responses. Over time, this helps reduce migraine frequency and severity by improving self-regulation of stress-related physiological triggers.

Correct Answer is C

Explanation

Rationale:
A. Clients experiencing anorexia, especially related to radiation therapy, are often more fatigued in the evening and may have a decreased appetite later in the day. It is generally more effective to encourage the largest meal earlier in the day when energy levels and appetite may be higher.

B. Clients undergoing radiation therapy require adequate protein intake to promote tissue repair and maintain strength. Low-protein supplements would not meet the increased metabolic and healing needs associated with cancer treatment and its side effects.

C. Radiation therapy, especially when affecting the head, neck, or gastrointestinal tract, can alter taste perception and increase nausea. Cold or room-temperature foods tend to have less odor and are often better tolerated, which can help improve appetite and reduce food aversions in clients experiencing anorexia.

D. Drinking large amounts of fluids with meals can create a sense of fullness and further reduce food intake, worsening anorexia. Instead, fluids are often encouraged between meals to help maintain hydration without interfering with caloric intake.

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