Nokea
Which assessment findings support a nurse's suspicion that a patient has been using inhalants?
- A. Pinpoint pupils and respiratory rate of 12 breaths per minute
- B. Perforated nasal septum and hypertension
- C. Drowsiness, euphoria, and constipation
- D. Nosebleed, muscle wasting, and impaired hearing
Correct Answer: D
Rationale: Inhalant use causes nosebleeds, muscle wasting, and sensory impairments like hearing loss.
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A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled 'lorazepam.' What is the nurse's first action?
- A. Test reflexes.
- B. Check pupils.
- C. Initiate vomiting.
- D. Establish a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority for an unconscious patient to prevent aspiration.
Select the nursing intervention necessary after administering naloxone to a patient experiencing an opiate overdose.
- A. Monitor the airway and vital signs every 15 minutes.
- B. Insert a nasogastric tube and test gastric pH.
- C. Treat hyperpyrexia with cooling measures.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Naloxone reverses CNS depression, but monitoring is needed as narcotics outlast the antagonist.
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.
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, 'After discharge, I think everything will be just fine.' Which remark by the nurse will be most helpful to the spouse?
- A. It is good that you're supportive of your spouse's sobriety and want to help maintain it.'
- B. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.'
- C. It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection.'
- D. Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully.'
Correct Answer: B
Rationale: This response provides anticipatory guidance about challenges in sobriety, helping the spouse prepare for new issues.
A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient withdrawal symptoms?
- A. Slurred speech, excessive drowsiness, and bradycardia
- B. Paranoid delusions, tactile hallucinations, and panic
- C. Runny nose, yawning, insomnia, and chills
- D. Anxiety, agitation, and aggression
Correct Answer: C
Rationale: Early narcotic withdrawal resembles flulike symptoms without fever.