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Difficulty: MediumHigh Risk Behaviors

A school nurse is evaluating a 17-year-old client who presents with severe insomnia, a resting heart rate of 115 beats/minute, and an unintentional 4.5 kg (10 lb) weight loss over the past month. The adolescent confides, "I have been taking unprescribed dextroamphetamine to stay awake and study for my college entrance exams. I just have to get a perfect score." Which of the following is the priority nursing action?

  1. A
    Ask the client why they believe their exam scores are more important than their physical well-being.
  2. B
    Initiate primary prevention by providing educational materials on healthy sleep hygiene and time management.
  3. Assess the client's cardiovascular status and monitor for signs of cardiac dysrhythmias.Answer
  4. D
    Notify the school's academic disciplinary board regarding the illicit use of a controlled substance on campus.

Answer

The correct action is to prioritize the client's physiological safety by assessing their cardiovascular status and monitoring for dysrhythmias.
According to Maslow's Hierarchy of Needs, physiological safety is the highest priority. Dextroamphetamine is a central nervous system stimulant that can cause severe cardiovascular complications, including hypertension, tachycardia, and dysrhythmias. The client is already exhibiting a resting heart rate of 115 beats/minute, indicating significant cardiovascular stress. The nurse must first assess the client's physical stability before addressing the psychosocial aspects of the high-risk behavior.

Step-by-Step Solution

1
Analyze the client's reported symptoms and history of substance use.
The client is exhibiting tachycardia, insomnia, and weight loss due to unprescribed stimulant use.
Identifying the physiological impact of the high-risk behavior is the first step in clinical judgment.
2
Apply Maslow's Hierarchy of Needs to prioritize nursing interventions.
Physiological needs (cardiovascular stability) take precedence over psychosocial needs (education, communication).
Stimulant toxicity can lead to life-threatening cardiac dysrhythmias or severe hypertension.
3
Evaluate the remaining options against therapeutic communication and legal standards.
Asking 'why' is non-therapeutic, primary prevention teaching is not the immediate priority, and reporting to an academic board breaches confidentiality.
Maintaining trust and focusing on immediate health risks aligns with nursing standards of care.

Key Concept

Prioritization of Care in Substance Misuse
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Topics

High Risk Behaviors

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