A patient who is withdrawing from alcohol is restless and reports seeing snakes on the ceiling. Vital signs are blood pressure 180/100 mm Hg, pulse 92 beats/min, and respirations 22 breaths/min. What should the nurse do first?
a. Teach the patient a relaxation technique.
b. Administer a dose of lorazepam (Ativan).
c. Search the patient's room for hidden alcohol.
d. Administer an antihypertensive agent as ordered.
ANS: D
According to Maslow's hierarchy, physiological symptoms must be attended to first. The patient's blood pressure is at an unsafe level. A. B. Once the patient's blood pressure is under control, then Ativan and relaxation may be helpful. C. Searching the room for alcohol is occasionally necessary, but a patient who has withdrawal symptoms is not likely using alcohol.
You might also like to view...
While assessing motor function, the nurse applies pressure to a toenail. What patient response is most normal?
A) Extension of both feet B) Flexion of knee and ankle C) Extension of one or both arms D) Kicking the nurse's hand away
Nurses who work in home care offering enteral, parenteral, intravenous, and blood transfusion services can prevent:
a. morbidity. b. hospitalization. c. hospice care. d. mortality.
A ________________________ journal is one that is not printed on paper. Standard Text:
Fill in the blank(s) with correct word
What are the goals of treatment for Parkinson's disease? (Select all that apply.)
a. Help the patient to maintain a high quality of life. b. Reduce side effects of drug therapy. c. Regain as much function as possible. d. Minimize the patient's disability. e. Prolong the patient's life span.