The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?
Dilated pupils, tachycardia, elevated blood pressure, elation.
Excessive eating, constipation, headache.
Nausea, vomiting, diaphoresis, anxiety, tremors.
Mood lability, poor hand coordination, fever, drowsiness.
The Correct Answer is C
A. Dilated pupils, tachycardia, elevated blood pressure, elation: These symptoms are more typical of stimulant intoxication and do not indicate alcohol withdrawal. They are not consistent with the need for a detox protocol focused on alcohol or other depressants.
B. Excessive eating, constipation, headache: These symptoms are not associated with alcohol or drug intoxication or withdrawal. They do not suggest a need for detoxification medication protocols.
C. Nausea, vomiting, diaphoresis, anxiety, tremors: These are classic signs of alcohol withdrawal and suggest the need for detoxification. These symptoms require immediate intervention to manage withdrawal safely and avoid complications.
D. Mood lability, poor hand coordination, fever, drowsiness: These signs are more indicative of intoxication with substances like sedatives. While concerning, they do not point to alcohol withdrawal, which requires specific detox protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.
B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.
C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.
D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"D"},"D":{"answers":"A"}}
Explanation
Rationale:
- Assessment: This describes the findings relevant to the current situation, such as the elevated digoxin level (2.2 ng/mL), the client’s heart rate (79 beats/minute), and the absence of symptoms such as decreased perfusion, indicating that the client is stable for now.
- Background: Provides necessary patient details, such as age, diagnosis (heart failure), and the fact that the client has been on digoxin for three days, so the nurse provides a brief clinical history relevant to the current issue.
- Recommendation: The nurse suggests rechecking the digoxin level the next day to assess if it has returned to the therapeutic range. Suggests an action to the healthcare provider (recheck digoxin level tomorrow) and indicates that the nurse will monitor the client closely for any changes.
- Situation: The nurse is holding the digoxin due to the elevated level, which exceeds the therapeutic range. This introduces the immediate reason for the call, explaining the context of the patient's condition and recent treatment.
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