Difficulty: Medium
Average Score: 89%
Simulated
Passage / Scenario
Vital Signs0830:
Temperature 35.1┬░ C (95.2┬░ F)
Heart rate 44/min
Respiratory rate 10/min
Blood pressure 84/45 mm Hg
Oxygen Saturation 90% on room air
Nurses' Notes
0800:
Client brought by ambulance to the ED with shallow breaths, slurred speech, confusion, and pupillary constriction. Minor abrasions noted on upper and lower extremities. Deep tendon reflexes (DTRs) 1+. Client vomited twice while in the care of emergency medical services. Family member fou the client lying on the sidewalk in front of the house. The client had not returned home last night, and the family member was going to see if the client's car was parked in the driveway.
Client's family member stated the client has had a change in their mood recently and was fired from their job for lack of attendance. The client came to live with the family member about 3 weeks ago after the client's partner divorced them, and they were without housing. The family member reports the client has been struggling for about a year with their back pain
A nurse is caring for a client in the emergency department (ED).Exhibits: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Rationale
Correct Answer: B: Stimulant intoxication, Alcohol intoxication, Opioid withdrawal
Rationale:
- The client is most likely experiencing substance intoxication or withdrawal based on the ED setting and the need for nursing intervention.
- Actions: Address the specific condition by providing appropriate care and support, such as monitoring vital signs and providing symptom relief.
- Parameters to monitor: Respiratory rate and cardiac arrhythmias to assess the client's physiological response to the substance ingested.
Summary:
- Choice A is incorrect because preparing for mechanical ventilation and administering clonidine are not appropriate initial interventions for substance intoxication or withdrawal.
- Choice C is incorrect because pupillary reaction, hyperreflexia, and ethanol level are not specific enough to determine the client's condition or guide nursing interventions.
- Choice D, E, F, G are not applicable or do not provide relevant information for the client's condition in the ED setting.
Rationale:
- The client is most likely experiencing substance intoxication or withdrawal based on the ED setting and the need for nursing intervention.
- Actions: Address the specific condition by providing appropriate care and support, such as monitoring vital signs and providing symptom relief.
- Parameters to monitor: Respiratory rate and cardiac arrhythmias to assess the client's physiological response to the substance ingested.
Summary:
- Choice A is incorrect because preparing for mechanical ventilation and administering clonidine are not appropriate initial interventions for substance intoxication or withdrawal.
- Choice C is incorrect because pupillary reaction, hyperreflexia, and ethanol level are not specific enough to determine the client's condition or guide nursing interventions.
- Choice D, E, F, G are not applicable or do not provide relevant information for the client's condition in the ED setting.