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?
- AAsk the client why they believe their exam scores are more important than their physical well-being.
- BInitiate primary prevention by providing educational materials on healthy sleep hygiene and time management.
- Assess the client's cardiovascular status and monitor for signs of cardiac dysrhythmias.Cevap
- DNotify the school's academic disciplinary board regarding the illicit use of a controlled substance on campus.
Cevap
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.
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Prioritization of Care in Substance Misuse