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 C
Explanation
A. Bradycardia: Alcohol withdrawal typically presents with tachycardia (increased heart rate), not bradycardia (decreased heart rate).
B. Hypotension: Alcohol withdrawal is more likely to cause elevated blood pressure rather than hypotension.
C. Elevated temperature: Elevated temperature is a common sign of alcohol withdrawal, which can be accompanied by other symptoms like tremors and agitation.
D. Slurred speech: Slurred speech is more associated with alcohol intoxication rather than withdrawal.
Correct Answer is D
Explanation
A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.
B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.
C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.
D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.
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