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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. This tablet has no score line and could have an extended-release or special coating that should not be altered. Cutting it may affect absorption and safety.

B. The triangular shape and lack of score line suggest it is not intended to be split, risking improper dosing or altered release.

C. The tablet in option C has a scored line (a groove down the middle), which indicates that it can be safely split. Scored tablets are manufactured to ensure even distribution of the active ingredient, making it safe for dose division.

D. This is a capsule, which should never be cut or opened unless specifically directed, as it may contain extended-release beads or irritants.

A. Frequency that the child uses a rescue inhaler during the week. B. Type of inhaler the child typically uses on a regular basis. C. Type of allergen exposure or trigger for the current episode. D. Last dose and type of rescue inhaler used by the child.

Correct Answer is D

Explanation

A. Frequency that the child uses a rescue inhaler during the week: While it is important to know how often the child uses a rescue inhaler, it does not provide immediate, critical information to assess the severity of the current asthma attack.

B. Type of inhaler the child typically uses on a regular basis: While knowing the type of inhaler the child uses regularly can provide insight into their asthma management, it is not the most critical information at this moment, the current treatment is he most urgent.

C. Type of allergen exposure or trigger for the current episode: Understanding the trigger for the current asthma episode is helpful for long-term management but is not as urgent in the immediate assessment of the child’s condition during an acute exacerbation.

D. Last dose and type of rescue inhaler used by the child: This information helps assess whether the child has received appropriate treatment and whether additional or different interventions are needed immediately to address the asthma exacerbation, helps guide further treatment decisions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which oral medication can the nurse safely cut in half?

Correct Answer is C

Explanation

A parent brings their child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Correct Answer is D

Explanation

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