NCLEX-PN® ExaminationPsychosocial IntegrityMedium
A practical nurse is assisting with the care of a client with a history of opioid use disorder. The client is currently experiencing symptoms of withdrawal, including nausea, vomiting, muscle cramps, and rhinorrhea. The nurse understands that which of the following is the primary goal of nursing care during acute opioid withdrawal?
- AFacilitate immediate abstinence from all substances.
- BInitiate long-term rehabilitation planning.
- CManage symptoms to promote comfort and prevent complications.
- DEducate the client about the dangers of opioid use.
Show answer & explanationAnswer & explanation
Correct answer: C. Manage symptoms to promote comfort and prevent complications.
During acute opioid withdrawal, the primary goal of nursing care is symptom management. Opioid withdrawal, while rarely fatal, is extremely uncomfortable and can lead to complications such as severe dehydration from vomiting and diarrhea. Managing these symptoms promotes comfort, prevents complications, and helps the client remain engaged in treatment.
Why the other options are wrong
- A. While abstinence is the ultimate goal, forcing 'immediate abstinence' without symptom management is not the primary goal during acute withdrawal, as it can be highly distressing and lead to relapse.
- B. Long-term planning is important but is secondary to managing the acute, immediate physical distress of withdrawal.
- D. Education is ongoing, but in the acute phase of severe discomfort, the client's ability to absorb and act on education is limited; symptom management takes precedence.
Opioid Withdrawal: Acute Care Goal
The primary goal of nursing care during acute opioid withdrawal is to manage and alleviate severe withdrawal symptoms to ensure client comfort, prevent complications, and facilitate continued engagement in treatment.
- Symptoms are highly distressing but rarely life-threatening.
- Complications can include dehydration and aspiration.
- Medication-assisted treatment (e.g., buprenorphine, clonidine) is often used for symptom management.
Memory trick: Comfort First, Then Recovery.