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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. In the event of a life-threatening situation, the immediate priority is to address the situation to stabilize the client's condition. If removing the weights from the traction device is necessary to manage the life-threatening situation then the nurse may remove the weights as part of the overall management of the client's care.

B. It's generally not necessary to remove the weights from the traction device for an x-ray of the femur. Instead, the x-ray can typically be performed with the weights in place.

C. Pain management is important for clients in traction, but removing the weights is not the initial action for addressing pain. The nurse should assess the cause of the pain and intervene appropriately.

D. Repositioning the client in the bed may be necessary for comfort, preventing pressure ulcers, or facilitating care activities. When repositioning the client, the nurse should ensure that the traction setup remains intact and that the weights are properly secured.

A. Malignant hypothermia B. Pulmonary embolism C. Fat embolism syndrome D. Acute compartment syndrome

Correct Answer is D

Explanation

D. Fractures, crush injuries, or tight casts can lead to compartment syndrome. Symptoms include severe pain, swelling, numbness or tingling, and decreased sensation or function of the affected limb.

Increasing edema in the calf is a hallmark manifestation of acute compartment syndrome and indicates a worsening of the condition.

A. Malignant hyperthermia is a rare but life-threatening complication that can occur in response to certain medications used during anesthesia. Edema in the calf is not a manifestation of malignant hyperthermia.

B. Pulmonary embolism occurs when a blood clot travels to the lungs and blocks blood flow. While pulmonary embolism can cause symptoms such as chest pain, shortness of breath, and cough, edema in the calf is not a typical manifestation of this condition.

C. Fat embolism syndrome occurs when fat globules are released into the bloodstream, often after long bone fractures or orthopedic procedures. Increasing edema in the calf is not a characteristic manifestation of fat embolism syndrome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

Correct Answer is A

Explanation

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

Correct Answer is D

Explanation

A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome?

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The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

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

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)