In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome.
a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization.
b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min.
c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department.
d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.
ANS: B
The correct short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.
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