Concepts of Family Health Care

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In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.

  • A. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
  • B. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department.
  • C. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
  • D. The patient will identify two community resources for the treatment of substance abuse by discharge.
Correct Answer: A

Rationale: The correct answer is A because stabilizing the patient's vital signs is the top priority in this critical situation. A blood pressure of 66/40 mm Hg indicates severe hypotension, which can lead to organ failure. A pulse of 140 bpm and shallow respirations of 8 bpm indicate poor perfusion and respiratory distress. Achieving a BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 bpm indicates improved perfusion and oxygenation, which are crucial for the patient's survival.

Option B is incorrect as achieving a drug-free state is not the immediate priority in an overdose situation. Option C is incorrect as attending Narcotics Anonymous meetings is important for long-term recovery but not the immediate priority. Option D is incorrect as identifying community resources for substance abuse treatment is important but not as critical as stabilizing the vital signs in an overdose situation.

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The treatment team plans care for a person diagnosed with paranoid schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning?

  • A. Consider each diagnosis primary and provide simultaneous treatment.
  • B. The person will benefit from treatment in a residential treatment facility.
  • C. Withdraw the person from cannabis, and then treat the symptoms of schizophrenia.
  • D. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
Correct Answer: A

Rationale: Correct Answer: A

Rationale:
1. Dual diagnosis: Simultaneous treatment is crucial as both conditions impact each other.
2. Cannabis withdrawal may worsen schizophrenia symptoms, so treating both concurrently is essential.
3. Addressing both diagnoses concurrently increases treatment effectiveness.
4. Residential treatment may not be necessary at this stage without considering simultaneous treatment.

Summary:
B: Residential treatment may not be needed immediately; focus on simultaneous treatment.
C: Withdrawal may worsen schizophrenia symptoms; treating both conditions concurrently is preferable.
D: Treating schizophrenia first may not address the immediate exacerbation of symptoms due to cannabis use.

Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?

  • A. Make physical contact by frequently touching the patient.
  • B. Offer intellectual activities requiring concentration.
  • C. Avoid manipulation by denying the patient’s requests.
  • D. Observe for depression and suicidal ideation.
Correct Answer: D

Rationale: The correct answer is D because observing for depression and suicidal ideation is crucial when caring for a patient withdrawing from CNS stimulants. Depression and suicidal ideation are common withdrawal symptoms, so monitoring for these signs is essential for the patient's safety. It allows for early intervention and appropriate support to prevent any harm.

Choice A is incorrect as frequent physical contact may not be appropriate and can potentially agitate the patient during withdrawal. Choice B is incorrect as intellectual activities requiring concentration may overwhelm the patient who is already going through withdrawal symptoms. Choice C is incorrect as denying the patient's requests can lead to increased agitation and resistance during withdrawal, which is not conducive to effective care.

What is the term that is used to describe a healthcare related incident or accident that may have possibly led to client harm?

  • A. An adverse event
  • B. A root cause
  • C. A healthcare acquired event
  • D. A sentinel event
Correct Answer: D

Rationale: Sentinel events are unexpected occurrences involving risk of serious harm.

An adult in the emergency department states, 'I feel restless. Everything I look at wavers. Sometimes I’m outside my body looking at myself. I hear colors. I think I’m losing my mind.' Vital signs are slightly elevated. The nurse should suspect a(n):

  • A. schizophrenic episode
  • B. cocaine overdose
  • C. phencyclidine (PCP) intoxication
  • D. D-lysergic acid diethylamide (LSD) ingestion
Correct Answer: D

Rationale: The correct answer is D, D-lysergic acid diethylamide (LSD) ingestion. LSD causes visual disturbances, dissociation, heightened sensory perceptions, and altered sense of reality, matching the client's symptoms. Vital signs being slightly elevated are consistent with LSD use. Schizophrenic episodes (A) involve long-term symptoms, not acute onset. Cocaine overdose (B) would present with more severe vital sign changes. PCP intoxication (C) typically causes aggression and hallucinations, not the described symptoms.

What nursing action is important to remember prior to administering Propranolol to a client with anxiety?

  • A. Check blood pressure first
  • B. Fine hand tremor
  • C. Headache
  • D. Selective serotonin reuptake inhibitors (SSRIs)
Correct Answer: A

Rationale: Correct Answer: A - Check blood pressure first

Rationale:
1. Propranolol is a beta-blocker used for anxiety and hypertension.
2. Before administering Propranolol, it's crucial to check the client's blood pressure, as it can cause hypotension.
3. Monitoring blood pressure helps prevent adverse effects like dizziness, fainting, or decreased perfusion.
4. Fine hand tremor (B) is a potential side effect of Propranolol, but it's not the priority before administration.
5. Headache (C) can be a side effect of Propranolol but is not the primary concern pre-administration.
6. Selective serotonin reuptake inhibitors (SSRIs) (D) are not directly related to the administration of Propranolol for anxiety.

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