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An agitated individual is brought to the emergency department by friends who state that the patient took a hallucinogenic drug at a party and then tried to jump from a second-story window. Which of the following nursing diagnoses is priority?
- A. Risk for injury related to altered sensation.
- B. Ineffective health maintenance related to ineffective coping strategies.
- C. Powerlessness related to insufficient knowledge to manage a situation.
- D. Ineffective denial related to insufficient sense of control.
Correct Answer: A
Rationale: Although all the diagnoses may be appropriate for the patient, the highest priority is to address the patient's immediate risk for injury.
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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.
The nurse is caring for a young adult patient who has inhaled cocaine and has been admitted to the emergency department with palpitations and shortness of breath. Which of the following actions ordered by the health care provider will the nurse implement first?
- A. Obtain a 12-lead ECG.
- B. Start O2 at 4 L/minute.
- C. Draw blood for drug screening.
- D. Infuse normal saline at 100 mL/hour.
Correct Answer: B
Rationale: The priority here is to ensure that oxygenation is adequate. The other orders also should be accomplished as soon as possible but are not the first priority.
The nurse is assessing a patient who has a history of alcohol use. Which of the following assessment data should the nurse expect?
- A. Low blood pressure
- B. Decreased heart rate
- C. Elevated temperature
- D. Abdominal tenderness
Correct Answer: D
Rationale: Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in patients with persistent alcohol use. The other problems are not typically associated with alcohol use.
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 with alcohol dependence who has been admitted to the hospital with chest pain. Twenty-four hours after admission, the patient becomes very tremulous and anxious. Which of the following actions should the nurse implement?
- A. Insert an IV line and infuse fluids.
- B. Promote oral intake to 3000 mL/day.
- C. Provide a quiet, well-lit environment.
- D. Administer opioids to provide sedation.
Correct Answer: C
Rationale: The patient's symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help to decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible.