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Zorluk: ZorSubstance Use and Other Disorders

A practical nurse (PN) is assisting with the admission of a client to an inpatient mental health unit. The client is acutely intoxicated with methamphetamine and experiencing paranoid delusions. The client is diaphoretic, pacing rapidly around the dayroom, and stating, "They followed me here, I know they are waiting right outside the window." Which of the following actions should the PN include in the client's immediate care? Select all that apply.

  1. Monitor the client's vital signs frequently for severe hypertension and tachycardia.Cevap
  2. Decrease environmental stimuli by maintaining low unit lighting and minimizing noise.Cevap
  3. C
    Stand close to the client to establish trust while explaining that the facility windows are secure.
  4. D
    Request a prescription for mechanical restraints to prevent the pacing client from exhausting themselves.
  5. E
    Provide reassurance by telling the client, "Everything is fine, and no one is going to hurt you here."
  6. Maintain a safe physical distance and ensure a clear exit path during all interactions.Cevap

Cevap

The correct actions include monitoring vital signs frequently for hypertension and tachycardia, decreasing environmental stimuli, and maintaining a safe physical distance with a clear exit path.
Clients experiencing acute methamphetamine intoxication and active paranoia require interventions that prioritize physical safety, physiologic stability, and de-escalation. Frequent vital sign monitoring is critical due to the risk of sympathetic nervous system overstimulation, which can cause hypertensive crisis, severe tachycardia, and hyperthermia. Decreasing environmental stimuli (dimming lights, reducing noise) helps lower sensory overload that feeds paranoid delusions. Furthermore, maintaining a safe physical distance and a clear exit path protects the nurse while preventing the client from feeling trapped, which could otherwise trigger an aggressive 'fight or flight' response.

Adım Adım Çözüm

1
Analyze the client's presentation and substance involved.
The client is intoxicated with methamphetamine (a powerful central nervous system stimulant) and is exhibiting paranoia, agitation (pacing), and sympathetic overactivation (diaphoresis).
Identifying the physiological and psychological effects of the specific substance guides immediate safety and medical priorities.
2
Determine physiological safety priorities.
Stimulant toxicity carries a high risk of cardiovascular collapse, hypertensive crisis, and hyperthermia, requiring frequent vital sign monitoring.
Airway, breathing, and circulation (including blood pressure and heart rate) remain the highest priority in acute toxicity.
3
Determine psychological and environmental safety priorities.
The nurse must reduce stimuli to avoid worsening the paranoia, maintain a safe distance so the client does not feel cornered, and avoid arguing with the delusions or offering false reassurance.
Proper de-escalation techniques and environmental management prevent the escalation of agitation into physical violence.

Anahtar Kavram

Nursing Management of Acute Stimulant Intoxication and Paranoia
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Konular

Substance Use and Other Disorders

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