The nurse monitors this client with a history of opioid abuse for which of the following signs and symptoms associated with opioid withdrawal?
1. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor
2. Increased appetite, irritability, anxiety, restlessness, anxiety, and altered concen-tration
3. Depression, high drug craving, fatigue with altered sleep (insomnia or hyper-somnia), hypertension, agitation, and paranoia
4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxi-ety, craving, diarrhea, and mydriasis
4
Rationale: Opioids are central nervous system depressants. They generally cause drowsiness and the feeling of being out of touch with the world. Withdrawal occurs within 12 hours after the last dose. "Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis" identifies the signs and symptoms associated with opioid with-drawal. "Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor" identifies signs associated with nicotine withdrawal. "Increased appetite, irritability, anxiety, restlessness, anxiety, and altered concentration" describes cocaine withdrawal. "Depres-sion, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), hypertension, agi-tation, and paranoia" describes alcohol withdrawal.
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A patient is being tested for bacterial meningitis. Which finding would the nurse evaluate as supporting that diagnosis?
1. The CSF is negative for glucose. 2. CSF is high in sodium. 3. The CSF is turbid in appearance. 4. The potassium level in the CSF is low.
A client is scheduled for a mastectomy as part of her treatment for breast cancer. As she is about to receive the preoperative medication, she tells the nurse that she does not want to have her breast removed but wants a lumpectomy
Which response indicates that the nurse is acting as a client advocate? A. Telling the client that her surgeon is excellent and knows what is best for her condition B. Calling the surgeon to come and explain all treatment options to the client C. Holding the client's hand and offering to pray with her for a good outcome to the surgery D. Arranging to have the client be visited after surgery by a person who has had a successful mastectomy and is a long-term survivor of cancer
After a ureterolithotomy, a female patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care?
a. Provide teaching about home care for both catheters. b. Apply continuous steady tension to the ureteral catheter. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops.
All of the following are recommendations to protect children from poisoning except
1. Allow children to observe an adult taking medications to teach them how to take them properly. 2. Always store medicines in their original containers and have safety-lock tops on all medications. 3. Anticipate a child's curiosity and place medications and poisonous items where they cannot be accessed. 4. Never put products such as kerosene, gasoline, or cleaning agents in another container (e.g., a soft drink bottle, cup, or bowl). 5. Read the label carefully before dispensing a medication.