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All the following medications are ordered for a patient admitted with a blood alcohol concentration of 0.8 mg%. Which of the following should the nurse administer first?
- A. Thiamine 100 mg IV daily
- B. Lorazepam 1 mg SL as needed
- C. Folic acid 0.4 mg PO daily
- D. Dextrose 5% in water over 8 hours
Correct Answer: A
Rationale: Thiamine is given to all patients with alcohol intoxication to prevent Wernicke's encephalopathy. Because Wernicke's encephalopathy can be precipitated by the administration of glucose solutions, the thiamine should be given before (or concurrently with) the 5% dextrose solution. Lorazepam would not be appropriate while the patient still has an elevated blood alcohol concentration (BAC). Folic acid also may be administered but is not as important as thiamine.
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A patient who is disoriented and agitated comes to the emergency department after using methamphetamine. Vital signs are blood pressure 162/98, heart rate 142 and irregular, and respirations 32. Which of the following actions is priority for the nurse to implement?
- A. Reorient the patient at frequent intervals.
- B. Monitor the patient's ECG and vital signs.
- C. Keep the patient in a quiet and darkened room.
- D. Obtain a health history including prior drug use.
Correct Answer: B
Rationale: The priority is to ensure physiological stability given that methamphetamine use can lead to complications such as myocardial infarction. The other actions also are appropriate but are not of as high a priority.
The nurse is caring for a patient admitted to the hospital after an automobile accident who has a blood alcohol concentration (BAC) of 48 mmol/L (0.22 mg%). The patient is alert and does not appear highly intoxicated. Which of the following nursing actions should the nurse implement?
- A. Maintain the patient on NPO status.
- B. Avoid the use of intravenous (IV) fluids.
- C. Administer acetaminophen for headache.
- D. Monitor frequently for anxiety, hyper-reflexia, and sweating.
Correct Answer: D
Rationale: The patient's assessment data indicate physiological dependence on alcohol, and the patient is likely to develop acute withdrawal such as anxiety, hyper-reflexia, and sweating, which could be life-threatening. Acetaminophen is not recommended because it is metabolized by the liver. IV thiamine and IV glucose solutions usually are given to intoxicated patients to prevent Wernicke's encephalopathy, and there is no indication that the patient should be NPO.
The nurse is caring for an adult patient who is experiencing acute intoxication. Which of the following time frames should the nurse anticipate for the resolution of acute intoxication responses?
- A. 4 hours
- B. 12 hours
- C. 24 hours
- D. 48 hours
Correct Answer: C
Rationale: Intoxication responses usually last less than 24 hours and are directly related to the ingestion of psychoactive substances.
A young adult patient arrives at the emergency department with severe chest pain and agitation. Which of the following actions should the nurse take first?
- A. Give the PRN naloxone IV.
- B. Ask about any use of stimulant drugs.
- C. Assess orientation to person, place, and time.
- D. Check blood pressure, pulse, respirations, and oxygen saturation.
Correct Answer: D
Rationale: The patient has symptoms consistent with the use of cocaine or amphetamines and is at risk for dysrhythmias, hypotension, heart failure, myocardial infarction, and cardiomyopathy. The nurse also will ask about drug use and assess orientation, but these are not the priority actions. Naloxone may be given if the patient develops symptoms of CNS depression, but this patient's current symptoms indicate stimulant use.
An older adult has been taking alprazolam and calls the clinic asking for a refill of the prescription 1 month before it should need to be refilled. Which of the following responses is most appropriate?
- A. The prescription cannot be refilled for another month. What happened to all of your pills?
- B. Do you have any muscle cramps or tremors if you don't take the medication frequently?
- C. I will ask the doctor to prescribe a few more pills, but you will not be able to get any more for another month.
- D. I am concerned that you may be overusing the alprazolam. Let's make an appointment for you to see the doctor today.
Correct Answer: D
Rationale: The patient should be assessed for problems that are causing overuse of the alprazolam, such as anxiety or memory loss. The other responses by the nurse will not allow for the needed assessment and possible referral for support services or treatment of drug dependence.