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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This description accurately reflects a greenstick fracture. In a greenstick fracture, the bone is partially fractured, typically on one side, while the other side remains intact. It is often compared to the way a green stick bends but does not break completely.
This description is more characteristic of a comminuted fracture, where the bone breaks into multiple fragments that may displace or splinter into the surrounding tissue.
This description is indicative of an impacted fracture, where the bone ends are driven into each other, often due to a compressive force.
This description is characteristic of an open or compound fracture, where the broken bone penetrates the skin and is exposed to the external environment.
Correct Answer is B
Explanation
B. Applying ice to the affected knee is a common postoperative instruction after arthroscopic knee surgery. Ice helps reduce swelling, inflammation, and pain in the surgical area. It is usually recommended to apply ice intermittently for short periods during the first 24 to 48 hours following surgery.
A. Keeping the leg in a dependent position, where it is hanging down, is not typically recommended following arthroscopic knee surgery.
C. Complete bedrest for the first 24 hours after arthroscopic knee surgery is not typically necessary or recommended. Early mobilization and gentle range of motion exercises are usually encouraged to prevent complications such as blood clots and joint stiffness.
D. These exercises help restore joint mobility, prevent stiffness, and promote healing of the surgical site. However, the timing and specific exercises should be guided by the surgeon's instructions and individual patient factors.
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