Nokea
The nurse is assessing a client who is a polysubstance abuser, with fentanyl being one of the drugs most frequently used. Which physiological symptoms are suggestive of fentanyl intoxication? Select all that apply.
- A. diarrhea
- B. nausea
- C. urge to urinate
- D. anxiety
Correct Answer: B
Rationale: Nausea is a common symptom of fentanyl intoxication. Diarrhea, urge to urinate, and anxiety are not typical physiological signs.
You may also like to solve these questions
The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action should the nurse include in the plan of care?
- A. Encouraging the child to confront the abuser
- B. Providing a care environment that fosters trust
- C. Teaching the child to make wise choices when faced with possible abuse
- D. Reinforcing for the child that not all adults are capable of abusing children
Correct Answer: B
Rationale: Providing a safe and trusting environment is critical for a child who has experienced physical abuse, as it helps the child feel secure and supported, facilitating emotional healing. Encouraging the child to confront the abuser is inappropriate and could be traumatic, especially for a young child. Teaching the child to make wise choices in potentially abusive situations places an unrealistic burden on the child, who may not have the capacity to protect themselves. Reinforcing that not all adults are abusive is less immediate and does not directly address the child's need for a safe and trusting care environment.
A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea-anxiety-dyspnea cycle?
- A. Guided imagery and limiting fluids
- B. Relaxation and breathing techniques
- C. Biofeedback and coughing techniques
- D. Distraction and increased dietary carbohydrates
Correct Answer: B
Rationale: Relaxation and breathing techniques are effective in interrupting the dyspnea-anxiety-dyspnea cycle by calming the client and improving respiratory efficiency. These techniques help reduce anxiety, which can exacerbate dyspnea, and promote controlled breathing to enhance oxygenation. Guided imagery may be helpful but limiting fluids is unrelated to managing dyspnea or anxiety. Biofeedback and coughing techniques are not primarily indicated for this cycle. Distraction and increased dietary carbohydrates do not directly address the cycle and may not provide immediate relief.
A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which should the nurse plan to include as part of one of these discussions?
- A. Ongoing fluid restriction
- B. The need for genetic counseling
- C. The risk of hypotensive episodes
- D. Depression regarding massive edema
Correct Answer: B
Rationale: Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and the extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
- A. The client's blood pressure is 180/96 mm Hg.
- B. The client has right-sided weakness.
- C. The client has tinnitus.
- D. The client invents elaborate, improbable events.
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.
A client diagnosed with hyperaldosteronism has developed kidney failure and states to the nurse, 'This means that I will die very soon.' Which is the most appropriate therapeutic response for the nurse to make to the client?
- A. You will do just fine.
- B. What are you thinking about?
- C. You sound discouraged today.
- D. I read that death is a beautiful experience.
Correct Answer: B
Rationale: The therapeutic response encourages the client to express their thoughts and feelings about their prognosis, facilitating open communication. Option 1 provides false reassurance, which can block communication. Option 3 labels the client's emotions without encouraging further exploration. Option 4 is inappropriate and does not address the client's specific concerns about their condition.