The client is withdrawing from opioids. Which symptoms best ...

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The client is withdrawing from opioids. Which symptoms best describe the results of the nurse's assessment?
 
  Standard Text: Select all that apply.
  1. Abdominal cramping and pain
  2. Dilated pupils
  3. Pinpoint pupils
  4. Diaphoresis
  5. Hypotension

Question 2

The nurse is caring for a client who is one day post surgery for an abdominal hysterectomy. The client is requesting morphine sulfate intravenous (IV), which is prescribed.
 
  The client rates her pain as 8 out of 10, with 10 being the most intense. The nurse says to another nurse on the unit, She really doesn't look like she is in pain. Maybe she is an addict. Which is the best response by the other nurse?
  1. Maybe you could tell her to do some distraction techniques first.
  2. You could call the doctor and get an order for an oral medication.
  3. I would give the morphine; pain is subjective, and we don't know her history.
  4. I would hold the medication until she looks like she is in pain.

[Kimmy]

Answer to Question 1

Correct Answer: 1,2,4
Rationale 1: Signs of opioid withdrawal include abdominal cramps and pain.
Rationale 2: The pupils will be dilated during opioid withdrawal, but will appear pinpoint when the client is using opioids.
Rationale 3: The pupils will be dilated during opioid withdrawal, but will appear pinpoint when the client is using opioids.
Rationale 4: Signs of opioid withdrawal include diaphoresis.
Rationale 5: The blood pressure will be elevated during opioid withdrawal but will be decreased when the client is using opioids.
Global Rationale: Signs of opioid withdrawal include abdominal cramp, pain, pupil dilation, and diaphoresis. Pupils will appear pinpoint when the client is using opioids, not during withdrawal. The blood pressure will be elevated during opioid withdrawal but will be decreased when the client is using opioids.

Answer to Question 2

Correct Answer: 3
Rationale 1: Distraction techniques would be a good adjunct to pain medication, but should not replace it.
Rationale 2: Calling the health care provider for an order for an oral medication is inappropriate on the first postop day.
Rationale 3: The response to pain varies among individuals; a client is not an addict just because she does not look like she is in pain. Pain is subjective; the client should be believed.
Rationale 4: Holding a pain medication the first postop day is inappropriate, since not all clients express pain in the same manner.
Global Rationale: The response to pain varies among individuals; a client is not an addict just because she does not look like she is in pain. Pain is subjective; the client should be believed. Distraction techniques would be a good adjunct to pain medication, but should not replace it. Calling the health care provider for an order for an oral medication is inappropriate on the first postop day. Holding a pain medication the first postop day is inappropriate, since not all clients express pain in the same manner.

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Gracias!

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Excellent