Nokea
The nurse is caring for a patient who is admitted to the hospital for treatment of an abscess on the left thigh and the patient tells the nurse that they use fentanyl illegally. Which of the following symptoms should the nurse anticipate assessing?
- A. Nausea and diarrhea
- B. Tremors and seizures
- C. Lethargy and disorientation
- D. Delusions and hallucinations
Correct Answer: A
Rationale: Symptoms of opioid withdrawal include gastrointestinal symptoms such as nausea, vomiting, and diarrhea, similar to a bout of the stomach flu. The other symptoms are seen during withdrawal from other substances such as alcohol, sedative-hypnotics, or stimulants.
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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 caring for a patient admitted to hospital with chest pain who is a pack-a-day smoker and tells the nurse, 'I am just not ready to quit smoking yet.' Which of the following responses is the most appropriate?
- A. This would be a really good time to quit.
- B. Your smoking is the cause of your chest pain.
- C. Do you think that smoking has caused any health problems?
- D. Are you familiar with the various nicotine replacement options?
Correct Answer: C
Rationale: The patient is in the precontemplation stage of change, and the nurse's role is to assist the patient in identifying motivators to quitting. The current Clinical Practice Guidelines indicate that the nurse should ask the patient to identify any negative consequences from smoking. The responses 'This would be a really good time to quit.' and 'Your smoking is the cause of your chest pain.' express judgmental feelings by the nurse and are not likely to motivate the patient. Providing information about the various nicotine replacement options would be appropriate for a patient who has expressed a desire to quit smoking.
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.
During physical assessment of a patient who has sinus headaches, the nurse finds nasal sores and necrosis of the nasal septum. Patient use of which of the following substances should the nurse include in the assessment?
- A. Heroin
- B. Cocaine
- C. Tobacco
- D. Marijuana
Correct Answer: B
Rationale: When cocaine is inhaled, it causes ischemia of the nasal septum, leading to nasal sores and necrosis. These symptoms are not associated with the use of heroin, tobacco, or marijuana.
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.