Author Question: After the nurse receives report, which patient should the nurse assess first? a. Patient who has ... (Read 49 times)

darbym82 · **on:** Jun 25, 2018

After the nurse receives report, which patient should the nurse assess first?

a. Patient who has a respiratory rate of 14 after overdosing on oxycodone (OxyContin)
b. Patient admitted with cocaine use who has an irregular heart rate of 142 beats/minute
c. Patient who is experiencing hallucinations and extreme anxiety after the use of marijuana
d. Patient with a history of daily alcohol use who is complaining of insomnia and diaphoresis

Question 2

After receiving change-of-shift report on four patients who are undergoing substance abuse treatment, which patient will the nurse assess first?

a. A patient who has just arrived for alcohol abuse treatment and states that the last drink was 3 hours ago
b. A patient who is agitated and experiencing nausea, occasional vomiting, and diarrhea while withdrawing from heroin
c. A patient who has tremors secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago
d. A patient who is being treated for cocaine addiction and is irritable and disoriented, with a pulse rate of 112 beats/minute

nixon_s · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
Because the patient with cocaine use has symptoms suggestive of a possible fatal dysrhythmia, this patient should be assessed immediately. The other patients should also be seen as soon as possible, but their clinical manifestations do not suggest that life-threatening complications may be occurring.

Answer to Question 2

ANS: C
The patient's tremors indicate risk for seizures and possible cardiac/respiratory arrest, which can occur with withdrawal from sedative-hypnotics. The greatest risk for these complications is during days three to five after stopping the drug. Opioid and stimulant withdrawal is uncomfortable, but not life threatening. Symptoms of alcohol withdrawal do not occur until 4 to 6 hours after the last drink.