The nurse is collecting data on prenatal clients at a clinic on a Native American reservation in Arizona. One client has risk factors for substance abuse. What physical sign or signs did the nurse assess that suggest substance abuse in this client?
Select all that apply.
A) Dilated pupils
B) Odor of alcohol on the breath
C) Frequent accidents or falls
D) Underweight
E) Dressed in jeans and a t-shirt
Answer: A, B, D
Physical signs of substance abuse include dilated or constricted pupils, inflamed nasal mucosa, evidence of needle "track marks" or abscesses, poor nutritional status, slurred speech or staggering gait, and an odor of alcohol on the breath. Frequent accidents or falls are behavioral signs of substance abuse. Wearing a jeans and t-shirt is not indicative of substance abuse.
You might also like to view...
A patient with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the patient:
• Will begin attending an activities group at the mental health outreach center. • Is worried about being able to pay for the therapy. • Does not know how to get from home to the outreach center. • Has an appointment to have blood work at the same time the activities group meets. • Wants to attend services at a church that is a half mile from the patient's home. • Which task(s) would be part of the role of a community mental health nurse? (Select all that apply.) a. Rearranging conflicting care appointments b. Negotiating the cost of therapy for the patient c. Arranging transportation to the outreach center d. Accompanying the patient to church services weekly e. Monitoring to ensure the patient's basic needs are met
A registered nurse working in a restorative care setting will focus on which areas? (Select all that apply.)
a. Providing extensive supportive care b. Providing one-on-one care to patients c. Promoting patient self-care d. Promoting independence e. Promoting dying at home
A patient brought to the emergency room following a motor vehicle accident has sustained multiple traumas including a head injury. Which of the following physical assessments related to the ear should be reported by the nurse immediately?
A) The malleus can be visualized during otoscopic examination. B) The tympanic membrane is pearly gray. C) Tenderness is reported by the patient when the mastoid area is palpated. D) Clear, watery fluid is draining from the ear.
The nurse is preparing to obtain a blood specimen. Which step should the nurse implement when preparing for venipuncture?
a. Tie the tourniquet in a knot. b. Use the tourniquet for at least 1 minute. c. Place the tourniquet 5 to 10 cm (3 to 4 inches) above the selected site. d. Apply the tourniquet tight enough to oc-clude distal pulses.