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","D","E"]
Explanation
A. Smoking has been associated with an increased risk of developing osteoarthritis, particularly in the knees and hips. Smoking may contribute to inflammation and oxidative stress, which can exacerbate joint damage.
D. Aging is a significant risk factor for osteoarthritis. As individuals age, the cartilage in their joints may naturally deteriorate over time, leading to the development of osteoarthritis.
E. Obesity is a well-established risk factor for osteoarthritis, particularly in weight-bearing joints such as the knees and hips. Excess body weight places increased stress on the joints, leading to accelerated wear and tear of the joint cartilage.
B. Bacteria are not typically associated with the development of osteoarthritis. Osteoarthritis is primarily a non-inflammatory condition related to wear and tear on the joints rather than an infectious process.
C. Diuretics are medications used to treat conditions such as hypertension and edema by increasing urine output. There is no direct evidence linking diuretic use to the development of osteoarthritis.
Correct Answer is B
Explanation
B. Phalen's sign is a test for carpal tunnel syndrome. It is positive when the client experiences numbness, tingling, or pain in the median nerve distribution (especially the thumb, index finger, middle finger, and half of the ring finger) within 1 minute of wrist flexion.
A. Cool extremities are not typically associated with carpal tunnel syndrome. They may indicate issues related to circulation rather than compression of the median nerve.
C. Trousseau's sign is a test for latent tetany, which is associated with hypocalcemia. It involves inflating a blood pressure cuff on the upper arm and observing for carpal spasm. It is not a manifestation of carpal tunnel syndrome.
D. A decreased radial pulse may indicate vascular issues or compression of the radial artery, not carpal tunnel syndrome.
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