After receiving change-of-shift report on four patients who are undergoing substance abuse treatment, which patient will the nurse assess first?
a. A patient who has just arrived for alcohol abuse treatment and states that the last drink was 3 hours ago
b. A patient who is agitated and experiencing nausea, occasional vomiting, and diarrhea while withdrawing from heroin
c. A patient who has tremors secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago
d. A patient who is being treated for cocaine addiction and is irritable and disoriented, with a pulse rate of 112 beats/minute
ANS: C
The patient's tremors indicate risk for seizures and possible cardiac/respiratory arrest, which can occur with withdrawal from sedative-hypnotics. The greatest risk for these complications is during days three to five after stopping the drug. Opioid and stimulant withdrawal is uncomfortable, but not life threatening. Symptoms of alcohol withdrawal do not occur until 4 to 6 hours after the last drink.
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With an intact oculocephalic reflex, the
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A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse?
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