A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

Reorient the patient at frequent intervals.

Monitor the patient's electrocardiogram.

Keep the patient in a quiet and darkened room.

Obtain a health history including prior drug use.

Answer and Explanation

The Correct Answer is B

B. Methamphetamine use can cause significant cardiovascular effects, including tachycardia, hypertension, and arrhythmias. Given the patient's presentation with an irregular heart rate and tachycardia, continuous cardiac monitoring through an ECG is essential to assess for any life-threatening arrhythmias or other cardiac complications.

A. Reorientation is important for patients who are disoriented, but in the case of a patient who has admitted to using methamphetamine and is exhibiting signs of agitation and tachycardia, the priority is to ensure the patient's safety and stabilize their condition.

C. While providing a calm environment is beneficial for patients who are agitated, it is not the most important action in this scenario.

D. Obtaining a comprehensive health history, including prior drug use, is important for understanding the patient's background and potential risk factors. However, in this acute situation where the patient is disoriented, agitated, and exhibiting signs of cardiovascular distress, the priority is to address the immediate medical needs and stabilize the patient's condition.

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Correct Answer is D

Explanation

D. Petechiae, which are small red or purple spots caused by bleeding under the skin, are a classic manifestation of fat embolism syndrome. They typically appear on the upper chest, axilla (armpit), and conjunctiva of the eyes. Petechiae result from the occlusion of small blood vessels by fat globules, leading to microvascular bleeding.

A Paresthesia distal to the fracture site is not a typical manifestation of fat embolism syndrome. Instead, paresthesia may suggest nerve compression or injury related to the fracture itself rather than fat emboli.

B Fever is not a specific manifestation of fat embolism syndrome. While fever can occur with various types of infections or inflammatory conditions, it is not a hallmark symptom of fat embolism.

C Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), which is a potential complication of lower limb fractures. However, it is not a typical manifestation of fat embolism syndrome.

A. A patient who had a tonsillectomy one week ago B. A patient who had a knee replacement surgery this morning C. A patient who had a hernia repair surgery yesterday D. A patient who had an appendectomy two days ago

Correct Answer is D

Explanation

D. Appendectomy is a common surgical procedure to remove the appendix and is considered a moderate surgical intervention. Early ambulation is generally encouraged for patients after appendectomy to prevent complications such as pneumonia, deep vein thrombosis, and ileus.

B. Knee replacement surgery is a major orthopedic procedure that requires early mobilization and rehabilitation to prevent complications such as blood clots, joint stiffness, and muscle weakness. However, the client needs more time before ambulation is initiated

A. Tonsillectomy is a relatively minor surgical procedure that typically does not significantly impact a patient's mobility or ability to ambulate. The patient who had a tonsillectomy one week ago is likely well-recovered and may not require immediate prioritization for ambulation.

C. Hernia repair surgery is typically considered a moderate surgical procedure. While early mobilization is generally beneficial for patients recovering from hernia repair surgery, it may not be as urgent as for patients undergoing major orthopedic surgeries like knee replacement.

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A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a fractured femur about fat emboli syndrome. Which of the following findings should the nurse include as a manifestation of a fat embolism?

Correct Answer is D

Explanation

A post-operative patient is scheduled for ambulation. Which of the following patients should be prioritized for ambulation?

Correct Answer is D

Explanation

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A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

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