The nurse is assessing a client presenting with diazepam intoxication.
What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

Decreased blood pressure.

Increased temperature.

Impaired physical coordination.

Nausea and appetite loss.

Respiratory depression.

Answer and Explanation

Correct Answer : A,C,E

Diazepam is a benzodiazepine that can cause central nervous system depression, which can manifest as decreased blood pressure, impaired physical coordination and respiratory depression. These signs and symptoms are consistent with benzodiazepine intoxication and may require treatment with flumazenil, a benzodiazepine receptor antagonist.

Choice B is wrong because increased temperature is not a sign of benzodiazepine intoxication. Benzodiazepines can cause hypothermia, or low body temperature, due to vasodilation and decreased metabolic rate.

Choice D is wrong because nausea and appetite loss are not signs of benzodiazepine intoxication. Benzodiazepines can cause gastrointestinal effects such as constipation, dry mouth and increased appetite.

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Correct Answer is B

Explanation

Pulse oximetry works by measuring the amount of light that passes through your finger and reaches a sensor on the other side.

The amount of light that is absorbed by your blood depends on how much oxygen it carries. Nail polish can block or reflect some of the light, making it harder for the pulse oximeter to get an accurate reading of your oxygen level.

Choice A is wrong because the color of your nailbed is not relevant for pulse oximetry.

The pulse oximeter does not measure the color of your nailbed, but the amount of light that passes through it.

Choice C is wrong because the sensor does not react with the nail polish causing an allergic reaction.

The sensor is a non-invasive device that does not touch your skin or nail polish directly.

Choice D is wrong because the chemicals in the nail polish do not cause falsely decreased readings of your oxygen level.

The chemicals in the nail polish do not affect the amount of oxygen in your blood, but only the amount of light that reaches the sensor.

Normal ranges for pulse oximetry vary depending on your health condition and altitude, but generally they are between 95% and 100%. If your pulse oximetry reading is lower than 90%, you may have hypoxia, which means your tissues are not getting enough oxygen.

A. Using automatic BP cuff with shivering client with history of an irregular heart rate. B. Pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature. C. Counting the client’s radial pulse who is supine with the forearm straight alongside the body. D. Counting the respirations for one full minute for a client with tachypnea.

Correct Answer is A

Explanation

Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.

This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.

The nurse should intervene and use a manual BP cuff with a stethoscope instead.

Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.

Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.

The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.

Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.

Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.

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The nurse is assessing a client presenting with diazepam intoxication. What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

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Correct Answer is A

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The nurse is assessing a client presenting with diazepam intoxication.
What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.