A client who has been receiving naloxone suddenly starts grimacing and moaning, moving his arms back and forth across his body, and drawing his legs up to his abdomen
Prior to administration the client was sleepy and calm. Assessment reveals that his respiratory rate is 18 breaths per minute. Which nursing diagnosis would most likely apply?
A) Acute Pain
B) Impaired Spontaneous Ventilation
C) Deficient Knowledge
D) Ineffective Coping
Ans: A
Feedback:
The client is exhibiting nonverbal indicators of acute pain, which can result after naloxone reverses the opioid's effects. The client's respiratory rate is 18 breaths per minute, so impaired spontaneous ventilation is not appropriate. There is nothing to indicate at the present time that the client has a knowledge deficit or that he is not coping well.
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