# A nurse is caring for a client with opioid use disorder who is experiencing withdrawal symptoms. Which nursing intervention should be the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319704  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a client with opioid use disorder who is experiencing withdrawal symptoms. Which nursing intervention should be the priority?

## 보기

1. Administer naloxone (Narcan) immediately
2. Monitor vital signs and provide supportive care **✔ 정답**
3. Encourage the client to participate in group therapy
4. Restrict visitors to prevent drug smuggling

**정답: 2**

## 해설

Monitoring vital signs and providing supportive care is the priority to ensure safety and manage physiological changes during opioid withdrawal. Other options are either inappropriate (naloxone for withdrawal) or less immediate (group therapy, visitor restriction).

## 심화 해설

Core Nursing Explanation
This question tests the priority nursing intervention for a patient experiencing Opioid withdrawal. The core principle is understanding the difference between an overdose (a life-threatening emergency requiring reversal) and withdrawal (a non-life-threatening but highly distressing syndrome requiring supportive management). The priority is always patient safety and managing the physiological instability caused by withdrawal.

**Key Concept Analysis**
Opioid withdrawal is not typically fatal, but it causes significant autonomic nervous system hyperactivity and extreme discomfort. Symptoms include anxiety, agitation, insomnia, yawning, rhinorrhea (runny nose), lacrimation (tearing), diaphoresis (sweating), piloerection (goosebumps), mydriasis (dilated pupils), nausea, vomiting, diarrhea, abdominal cramps, and tachycardia. The priority is to monitor for and manage these physiological changes to prevent complications like dehydration, electrolyte imbalance, and self-harm due to distress.

**Answer Rationale**
Key Point! The correct answer is Monitor vital signs and provide supportive care. This is the priority because:
1. **Safety First:** Continuous monitoring of vital signs (especially heart rate and blood pressure) is essential to track the severity of withdrawal and detect any complications.
2. **Supportive Care is the Standard:** Management of opioid withdrawal is primarily supportive. This includes providing a calm environment, ensuring hydration (oral or IV), administering medications like clonidine (to reduce autonomic symptoms) or buprenorphine (for medication-assisted treatment), managing nausea and diarrhea, and providing comfort measures.
3. **Addresses Immediate Needs:** This intervention directly targets the patient's current, acute physiological distress, which is the most urgent nursing concern.

**Distractor Analysis**
Watch out for confusion!

- **① Administer naloxone (Narcan) immediately:** Naloxone is an opioid **antagonist** used to reverse the life-threatening respiratory depression of an opioid overdose. Administering it to a patient in withdrawal, who already has a low opioid level, would be ineffective and could potentially worsen symptoms. This is a critical distinction.

- **③ Encourage the client to participate in group therapy:** While psychosocial interventions and therapy are crucial components of long-term treatment for Opioid Use Disorder (OUD), they are not the priority during the acute withdrawal phase. The patient is likely too physically ill and distressed to engage meaningfully in therapy.

- **④ Restrict visitors to prevent drug smuggling:** Maintaining a safe, drug-free environment is an important **security** measure, especially in an inpatient detoxification unit. However, it is not the *priority* nursing intervention for managing the patient's acute physiological withdrawal symptoms. The nurse's first responsibility is to the patient's direct clinical status.

**Related Concepts**
The nursing process guides us: **Assessment** (vital signs, symptom severity) comes before **Intervention**. Supportive care aligns with the principle of managing the autonomic symptoms of withdrawal. Understanding this prioritization is also key for other substance withdrawal syndromes (e.g., alcohol, benzodiazepines), though their acuity and risks differ.

Concept Summary

| Concept | Description | Nursing Implication |
| --- | --- | --- |
| Opioid Overdose | Triad: Respiratory depression, pinpoint pupils (miosis), decreased level of consciousness. | Emergency! Administer Naloxone (Narcan), support airway/breathing. |
| Opioid Withdrawal | Syndrome of autonomic hyperactivity: anxiety, GI upset, piloerection, dilated pupils (mydriasis), tachycardia. | Priority: Supportive care, monitor vital signs, comfort measures, medication (clonidine, buprenorphine). |
| Supportive Care | Non-pharmacological and pharmacological management of symptoms to ensure safety and comfort. | Hydration, nutrition, symptom management (anti-emetics, anti-diarrheals), emotional support. |

Side-by-Side Comparison!

| Feature | Opioid Overdose | Opioid Withdrawal |
| --- | --- | --- |
| Mechanism | Excessive opioid agonism | Absence of opioid in a dependent body |
| Pupils | Pinpoint (Miosis) | Dilated (Mydriasis) |
| Respirations | Depressed, slow, shallow | Normal or increased |
| Level of Consciousness | Decreased, stupor, coma | Agitated, anxious, alert |
| Priority Intervention | Administer Naloxone (Narcan), ABCs | Monitor vital signs, provide supportive care |

Anatomy, Physiology & Pharmacology Points

- **Pathophysiology:** Chronic opioid use leads to neuroadaptation. Sudden cessation causes a rebound hyperactivity of the noradrenergic system in the locus coeruleus, producing the autonomic withdrawal symptoms.

- **Pharmacology - Naloxone:** A pure opioid antagonist with a high affinity for mu-opioid receptors. It competitively displaces opioids, reversing effects within minutes. Short half-life means re-dosing or continuous infusion may be needed.

- **Pharmacology - Withdrawal Meds:** Clonidine (an alpha-2 agonist) reduces sympathetic outflow, easing autonomic symptoms. Buprenorphine (a partial agonist) can be used for managed withdrawal (detox) or maintenance therapy.

Memory Tips

- **Withdrawal vs. Overdose:** Think "**W**ithdrawal = **W**ide pupils, **W**ired (agitated)". "**O**verdose = **O**ut of it, **O**pioids overwhelming".

- **Priority:** "First, keep them safe (monitor), then you can talk (therapy)."

- **Naloxone Use:** Remember the "**OPIOD**" mnemonic for overdose signs: **O**btunded, **P**inpoint pupils, **I**nfrequent breathing, **O**pioid use suspected, **D**eath imminent if no action.

High-Frequency NCLEX Topics
NCLEX loves testing your ability to **distinguish between overdose and withdrawal** and to prioritize **physiological stability over psychosocial interventions** in acute situations. Expect questions on the appropriate use of naloxone, signs of opioid withdrawal, and the nurse's role in supportive care during detoxification.

Watch Out for Question Variations!

- Instead of asking for the priority intervention, it might ask: "**Which finding requires immediate intervention?**" Correct answer would be a sign of *overdose* (e.g., respiratory rate of 8/min), not a withdrawal symptom.

- The question could shift to **alcohol withdrawal**, which is potentially life-threatening (risk of seizures, delirium tremens). The priority there would be monitoring for and preventing these complications, often with benzodiazepines.

- It might ask about **patient education** for someone prescribed naloxone: "Teach the family to administer it for signs of overdose (slow breathing, unresponsiveness) and to call 911 immediately."

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario:** You are the nurse on a medical detox unit. J.M., a 32-year-old with severe Opioid Use Disorder (heroin), was admitted 12 hours ago after their last use. They are now restless, pacing, complaining of severe stomach cramps and muscle aches. Their vital signs are: BP 150/92, HR 112, RR 22, Temp 37.8°C (100°F). They are yawning frequently and have a runny nose.

**Nursing Intervention Strategy:**
1.  **Assessment & Monitoring:** Your priority is a thorough assessment. Use a standardized tool like the Clinical Opiate Withdrawal Scale (COWS) to objectively score symptoms (restlessness, GI upset, pupil size, etc.). Monitor vital signs every 1-2 hours initially. This quantifies the severity and guides medication administration.
2.  **Supportive Care Implementation:**

- **Environment:** Provide a quiet, low-stimulation room. Ensure safety (padded side rails if risk of seizure from co-occurring withdrawal).

- **Hydration & Nutrition:** Encourage oral fluids. If nausea/vomiting is severe, anticipate an order for IV fluids (e.g., Normal Saline) to prevent dehydration and electrolyte imbalance. Offer small, bland meals.

- **Comfort & Symptom Management:** Administer ordered medications promptly: Clonidine for hypertension and autonomic symptoms, antiemetics (e.g., ondansetron) for nausea, antidiarrheals (e.g., loperamide) as needed. Provide warm blankets for chills/piloerection.

- **Psychosocial Support:** Use a calm, non-judgmental demeanor. Acknowledge their discomfort: "I know this is really hard. We're here to help you through it." Provide simple, clear information.

3.  **Evaluation:** Re-assess using the COWS scale after interventions. Document trends in vital signs and symptom severity. The goal is a safe, comfortable withdrawal and engagement in the next steps of treatment.

**Patient Safety and Precautions:**

- **Contraindication Alert:** Do not administer stimulants or medications that increase sympathetic activity.

- **Fall Risk:** Agitation and autonomic instability increase fall risk. Implement fall precautions.

- **Underlying Conditions:** Assess for co-occurring medical or psychiatric conditions (e.g., chronic pain, depression) that complicate management.

Nursing Procedure & Medication Flow
**Procedure: Monitoring a Patient in Opioid Withdrawal**
1. Introduce yourself and explain the frequent monitoring.
2. Perform and document vital signs per protocol (e.g., q1h for first 6 hrs).
3. Complete the COWS assessment simultaneously.
4. Report significant changes: HR >120, SBP >160, severe agitation, or new neurological symptoms.
5. Administer ordered supportive medications (note: clonidine can cause hypotension—monitor BP after giving).
6. Document all assessments, interventions, and patient responses.

**Medication: Clonidine for Withdrawal**

- **Action:** Central alpha-2 agonist, reduces sympathetic nervous system outflow.

- **Nursing Considerations:** Monitor for hypotension, dizziness, dry mouth. Advise patient to rise slowly. Do not stop abruptly.

A Word from Your Senior Nurse
"Nursing patients through withdrawal is challenging but profoundly important work. You are their anchor during a storm of physical and emotional turmoil. Remember, your calm presence and diligent monitoring are therapeutic interventions in themselves. On the NCLEX and in practice, never lose sight of the ABCs and basic physiological needs. Managing withdrawal isn't about fancy treatments; it's about excellent fundamental nursing care—monitoring, hydrating, comforting, and advocating. That's how you keep your patient safe and build the trust necessary for them to engage in recovery. You've got this!"

## 핵심 개념

- **Opioid Use Disorder** — A chronic, relapsing brain disease characterized by compulsive opioid use despite harmful consequences. Diagnosis is based on criteria in the DSM-5, including impaired control, social impairment, risky use, and pharmacological criteria (tolerance/withdrawal).
- **Naloxone** — An opioid receptor antagonist used as an emergency treatment for opioid overdose. It rapidly reverses respiratory depression, sedation, and hypotension by displacing opioids from receptor sites. It has a short duration of action.
- **Clinical Opiate Withdrawal Scale** — A standardized, 11-item tool used to rate common signs and symptoms of opioid withdrawal and monitor their severity over time. It helps guide clinical decision-making for medication administration during detoxification.
- **Supportive Care** — A cornerstone of medical management that focuses on relieving symptoms, preventing complications, and improving patient comfort, rather than curing the underlying disease. In withdrawal, it includes hydration, symptom management, and a therapeutic environment.
- **Clonidine** — A centrally-acting alpha-2 adrenergic agonist. It is used off-label to manage autonomic symptoms of opioid withdrawal (e.g., anxiety, agitation, tachycardia, hypertension) by reducing sympathetic nervous system activity.

## 같은 주제 문제

- [A nurse is assessing a 28-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=319705)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._