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Zorluk: OrtaSubstance Use and Other Disorders

A client is admitted to the telemetry unit experiencing acute cocaine toxicity. The client is highly agitated, profusely diaphoretic, and reports a racing heart. When assisting with the care of this client, which actions are appropriate for the practical nurse (PN) to execute? Select all that apply.

  1. Implement seizure precautions by padding the side rails and ensuring suction equipment is readily available.Cevap
  2. Decrease environmental stimuli by dimming the room lights and turning off the television.Cevap
  3. Measure vital signs frequently and promptly report any irregular heartbeats to the registered nurse (RN).Cevap
  4. D
    Encourage the client to pace continuously in the hallway to burn off their hyperactive energy.
  5. E
    Accept a task delegated by the charge nurse to administer an intravenous (IV) push benzodiazepine.
  6. F
    Provide comfort by telling the client, "You are perfectly safe here, so there is absolutely nothing to worry about."

Cevap

The appropriate actions for the practical nurse include implementing seizure precautions, decreasing environmental stimuli, and monitoring vital signs frequently to report any cardiovascular abnormalities.
Cocaine is a potent central nervous system (CNS) and cardiovascular stimulant. Care focuses on preventing severe complications such as seizures and cardiovascular collapse. Implementing seizure precautions ensures physical safety in the event of severe neurological hyper-excitability. Decreasing environmental stimuli helps lower CNS irritability, which can reduce agitation and the risk of seizures. Frequent vital sign monitoring and reporting irregular rhythms are critical data collection tasks safely within the PN scope to detect early signs of cardiovascular compromise, such as dangerous tachycardia or hypertension.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and the substance involved.
The client has acute cocaine toxicity, which is a powerful central nervous system (CNS) and cardiovascular stimulant.
Understanding the specific physiological effects of the toxic substance is essential for anticipating complications and prioritizing safety.
2
Identify the major life-threatening risks associated with this specific toxicity.
The primary emergent risks include myocardial infarction, fatal arrhythmias, and generalized seizures.
Anticipating worst-case clinical scenarios directs the implementation of necessary preventive measures, such as seizure pads and cardiac monitoring.
3
Select interventions that address these risks while remaining strictly within the practical nurse (PN) scope of practice.
The PN should implement seizure precautions, reduce environmental stimuli to lower CNS irritability, and closely monitor cardiovascular data without accepting out-of-scope tasks like IV push medication administration.
Adhering to the legal scope of practice ensures client safety and professional compliance while effectively contributing to the multidisciplinary care plan.

Anahtar Kavram

Nursing care for acute stimulant toxicity involves minimizing central nervous system stimulation, preventing injury from seizures, and closely monitoring for life-threatening cardiovascular complications within the legal scope of practice.
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Substance Use and Other Disorders

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