An unconscious client who has just been involved in a motor vehicle accident is brought to the emergency department
Which presenting clinical manifestation makes the nurse suspi-cious of an opioid overdose rather than increased intracranial pressure as a cause of the un-consciousness? A. Pinpoint pupils
B. Respiratory depression
C. Hyporeflexive deep tendon reflexes
D. Evidence that the client has vomited
A
Morphine and other opioids bind tightly to the mu (ยต) opioid receptor, which causes pupillary constriction. Head injuries resulting in increased intracranial pressure cause pupillary dilation. A symptom of withdrawal from opioids is pupillary dilation.
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The nurse understands that the following definitions of pain are appropriate to assimilate into one's practice:(Select all that apply) Standard Text: Select all that apply
1. Pain is whatever the experiencing person says it is 2. Client's often exaggerate pain 3. Pain is one of the body's defense mechanisms indicating that a problem exists 4. The client is the authority on the pain that he or she is experiencing 5. The nurse needs to be willing to believe that the client is experiencing pain
The patient's home has been demolished by a tornado. The patient's spouse and child were killed and the spouse is in need of a leg amputation. The nurse realizes that which of the following is true?
a. The patient will deal with his losses using usual coping strategies. b. A patient's normal coping strategies are always adequate. c. Patients usually seek new strategies to deal with loss. d. At the end of life, people still rely on the usual coping strategies.
Which observed behavior would indicate to the nurse that a postpartum client had progressed to the "taking-hold" phase?
a. Allows staff to perform most of infant's care b. Hesitates to initiate contact with the baby c. Questions nurse about the amount of formula her baby should be taking d. Requests between-meal snacks
The nurse notes a positive shifting dullness. Which diagnosis does this assessment finding support?
1) Ascites 2) Liver enlargement 3) Pancreatitis 4) An abdominal mass