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Zorluk: OrtaChemical and Other Dependencies / Substance Use Disorders

A client arrives at a community health clinic reporting severe muscle aches, insomnia, stomach cramps, and a constantly runny nose that began early in the morning. During the interview, the nurse observes that the client is highly restless, yawning frequently, and has noticeably dilated pupils. The client insists on receiving a strong antibiotic to treat these "severe flu symptoms." Which response or action by the nurse is the priority?

  1. Inquire about the client's recent use of and potential sudden cessation of prescription or illicit opioids.Cevap
  2. B
    Initiate standard and droplet precautions while assessing for recent exposure to influenza.
  3. C
    Ask the client why they believe an antibiotic is necessary for a suspected viral infection.
  4. D
    Delegate the collection of baseline vital signs to the unlicensed assistive personnel.

Cevap

The priority action is to inquire about the client's recent use and potential cessation of opioids, as the symptom cluster strongly indicates opioid withdrawal.
The client's presentation of rhinorrhea, myalgia, insomnia, gastrointestinal distress, restlessness, yawning, and mydriasis (dilated pupils) are classic physiological signs of opioid withdrawal. Recognizing this specific cluster of symptoms is crucial for the nurse to initiate a targeted substance use history and appropriate interventions rather than mistakenly treating the presentation as a standard infectious disease.

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1
Analyze the client's physical symptoms and behavioral cues.
The client presents with myalgia, insomnia, abdominal cramping, rhinorrhea, restlessness, yawning, and mydriasis.
Identifying the specific symptom cluster is necessary to differentiate between a standard infectious process and substance-related emergencies.
2
Synthesize the findings to formulate a clinical suspicion.
The combination of symptoms matches the classic clinical presentation of acute opioid withdrawal, not influenza.
Flu typically presents with fever, dry cough, and fatigue, whereas yawning, pupil dilation, and severe restlessness are hallmark indicators of opioid withdrawal.
3
Determine the priority nursing intervention based on the assessment.
The nurse must immediately assess for substance use history to confirm the suspicion and guide medical management.
Accurate identification of withdrawal is required to implement safety measures, prevent symptom escalation, and provide targeted pharmacological support.

Anahtar Kavram

Opioid Withdrawal Clinical Manifestations
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Konular

Chemical and Other Dependencies / Substance Use Disorders

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