A client is seen in the 24-hour drug clinic. She's thin, tense, jittery, and has dilated pupils and bad
breath. She tells the nurse "I have been speeding, and now I am burning up and need help.".
She
permits an oral temperature to be taken (it is 104° F), but then becomes suspicious and moves away
from staff, refusing to allow further examination. She states, "You could be trying to kill me.". The
assessment that can be made is the client is most likely under the influence of
a. PCP.
b. heroin.
c. barbiturates.
d. amphetamines.
D
The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are
also present. Amphetamine use should be suspected. Option A: PCP use would probably result in
bizarre, violent behavior. Options B and C would result in symptoms of CNS depression.
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An older client on Medicare has physical limitations and telephones a local home care agency to schedule a nurse to visit. What should the nurse do first before proceeding with this client's request?
1. Determine homebound status 2. Identify available staff to visit the client 3. Discuss the challenges the client is facing 4. Find out when the client was last hospitalized
When assisting the older adult who is despondent about the need to leave his home, the nurse uses which technique?
a. Ask him if he has a drinking problem. b. Explore the option of his moving in with someone. c. Reminisce with the patient and review his life. d. Assess for hopelessness and helplessness.
A patient is to receive 200 mg of fluconazole (Diflucan) by intravenous (IV) piggyback over the next hour. The piggyback bag containing the fluconazole has a total of 120 mL and the drop factor of the administration set is 15 gtt/mL
How many drops per minute are needed to administer the 200 mg of fluconazole in 1 hour? What is the answer?
Identify the additional assessment the nurse should make when the serum uric acid level of a 64-year-old man is 12.8 mg/dL
a. Glasgow coma scale each shift b. Heart sounds every 4 hours for murmurs and clicks c. Flank region every 12 hours for kidney tenderness d. Joints for tenderness and swelling