Symptoms of withdrawal from opioids for which the nurse should assess include:

a. dilated pupils, tachycardia, elevated blood pressure, and elation.
b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.
c. mood lability, incoordination, fever, and drowsiness.
d. excessive eating, constipation, and headache.


ANS: B
The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)

Nursing

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A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first?

a. Encourage range-of-motion exercises. b. Document the finding and monitor the client. c. Take vital signs, including temperature. d. Assess pain and administer pain medication.

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Health care is static

a. True b. False A) True B) False

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The nurse is assessing a child who is suspected of having Guillain-Barré syndrome. Which assessment findings would the nurse correlate as supporting this diagnosis? Select all answers that apply

A) Recent cytomegalovirus infection B) Hyperactive deep tendon reflexes C) Numbness in the lower extremities D) Sustained clonus E) Difficulty swallowing

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Sarah is a second-year nursing student. The clinical instructor overhears Sarah telling a patient that she "always" checks patients' bracelets before giving medication and she is not sure how the nurses on the unit "get away with" not

making more errors than they do. The clinical instructor pulls Sarah aside and explores with her how her communication might affect the patient and what it reflects about her beliefs related to the team. The actions of the clinical instructor reflect competencies outlined by: a. QSEN. b. IHI. c. DNV/NIAHO. d. AHRQ.

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