Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:
hypokalemia or hyponatremia.
acute gastrointestinal bleed.
increased intracranial pressure.
respiratory depression.
The Correct Answer is D
A. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.
B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.
C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.
D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increasing forgetfulness and confusion: These symptoms are more characteristic of Alzheimer's disease or other types of dementia, not Parkinson's disease. While cognitive decline can occur in later stages of PD, it is not typically an initial symptom.
B. Tremors and muscle rigidity: Tremors (often starting in one hand) and muscle rigidity are hallmark initial symptoms of Parkinson's disease. These motor symptoms are among the most common early manifestations.
C. Visual disturbances and muscle weakness: Visual disturbances are not typically associated with early Parkinson's disease, and muscle weakness is not an initial symptom but could occur later due to rigidity and bradykinesia.
D. Fatigue and respiratory difficulties: While fatigue can occur, respiratory difficulties are not typically initial symptoms of Parkinson's disease and are more associated with later stages or other conditions.
Correct Answer is A
Explanation
A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.
B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.
C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.
D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.
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