Nokea
In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats/min (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone. What is the priority outcome for this patient?
- 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: Stabilizing vital signs is the priority for an opiate overdose.
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A patient was admitted 1 day ago with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, 'Somebody tied me up with ropes.' The patient's response is described by what term?
- A. An illusion
- B. A delusion
- C. Hallucinations
- D. Hypnagogic phenomenon
Correct Answer: A
Rationale: The patient is misinterpreting a sensory perception when seeing a rope instead of traction. Illusions are common in early withdrawal from alcohol.
A patient in an alcohol treatment program says, 'I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober.' Which nursing diagnosis applies?
- A. Chronic low self-esteem
- B. Situational low self-esteem
- C. Disturbed personal identity
- D. Ineffective health maintenance
Correct Answer: A
Rationale: Lifelong feelings of inadequacy indicate chronic low self-esteem.
Which treatment approach is most appropriate for a patient with poor social skills who has been treated several times for substance addiction but has relapsed?
- A. 1-week detoxification program
- B. Long-term outpatient therapy
- C. 12-step self-help program
- D. Residential program
Correct Answer: D
Rationale: Residential programs promote lifestyle changes and skill development, effective for those with poor social skills.
A patient is admitted in a comatose state after ingesting five capsules of lorazepam. A friend of the patient says, 'Often my friend drinks, along with taking more of the drug than is prescribed.' What is the effect of the use of alcohol with this drug?
- A. The drug's metabolism is stimulated.
- B. The drug's effect is diminished.
- C. A synergistic effect occurs.
- D. There is no effect.
Correct Answer: C
Rationale: Alcohol and lorazepam, both CNS depressants, have synergistic effects, potentiating each other.
A patient admitted for a heroin overdose received naloxone. The patient's breathing pattern improved. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, 'I feel terrible.' Which analysis is correct?
- A. The patient is exhibiting a prodromal symptom of seizures.
- B. An idiosyncratic reaction to naloxone is occurring.
- C. Symptoms of opiate withdrawal are present.
- D. The patient is experiencing a relapse.
Correct Answer: C
Rationale: Naloxone precipitates opiate withdrawal, causing flulike symptoms.