Which intervention will the nurse caring for a patient suspected of phencyclidine (PCP) abuse implement based on an understanding of the medication's unique properties?
a. Assessing for chronic renal failure
b. Focusing attention on providing patient safety
c. Implementing suicide precautions immediately
d. Monitoring for delayed development of psychotic symptoms
ANS: D
Phencyclidine (PCP) is a hallucinogen, but it has its own set of CNS reactions. PCP has a long duration of action that can result in delayed psychotic symptoms. Chronic renal failure would not be immediately observable. Patient safety is a nursing responsibility regardless of the diagnosis. Self-harm is not generally a characteristic of this type of substance abuse.
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1. "Your liver isn't making any of the substance that makes stools brown.". 2. "The bilirubin that causes the coloration is going into your blood and turning your skin yellow.". 3. "It is being released into your bloodstream and turning your blood darker red.". 4. "The answer is not known. More research is needed regarding this question.".
After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?
a. "I can expect some nausea as a side effect of nitroglycerin." b. "I should only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."
A female patient who is taking trimethoprim-sulfamethoxazole (TMP-SMZ) (Bactrim, Septra) to treat a urinary tract infection reports vaginal itching and discharge. The nurse will perform which action?
a. Ask the patient if she might be pregnant. b. Reassure the patient that this is a normal side effect. c. Report a possible superinfection to the provider. d. Suspect that the patient is having a hematologic reaction.
When applying restraints to a patient in a chair, the hips should be near the ____________________ of the seat.
Fill in the blank(s) with the appropriate word(s).