A nurse is caring for a client who has a history of substance use disorder and is experiencing withdrawal symptoms. Which of the following actions should the nurse take first?
Assess the client's vital signs and level of consciousness.
Administer the prescribed medication for withdrawal symptoms.
Provide a calm and supportive environment for the client
Refer the client to a substance abuse counselor or program
The Correct Answer is A
Correct answer: a) Assess the client's vital signs and level of consciousness.
Rationale: According to the priority-setting framework, the nurse should first address the client's physiological needs before addressing their psychological or social needs. Therefore, the nurse should first assess the client's vital signs and level of consciousness, which can be altered by withdrawal symptoms, and intervene accordingly.
Incorrect choices:
b) Administer the prescribed medication for withdrawal symptoms.: This is an important action but not the first one as the nurse should first assess the client's condition and determine if they need any immediate interventions.
c) Provide a calm and supportive environment for the client.: This is an important action but not the first one as it addresses the client's psychological needs, which are lower in priority than their physiological needs.
d) Refer the client to a substance abuse counselor or program.: This is an important action but not the first one as it addresses the client's social needs, which are lower in priority than their physiological or psychological needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct answer: b) Flumazenil
Rationale: Flumazenil is an antidote for benzodiazepine overdose as it reverses its sedative effects by blocking its action on the GABA receptors.
Incorrect choices:
a) Naloxone: This is an antidote for opioid overdose as it displaces opioids from their receptors and restores respiration.
c) Acetylcysteine: This is an antidote for acetaminophen overdose as it replenishes glutathione and prevents liver damage.
d) Atropine: This is an antidote for organophosphate poisoning as it blocks the effects of acetylcholine and relieves bronchoconstriction and bradycardia.
Correct Answer is D
Explanation
Correct answer: d) "Methadone will block the effects of opioids if I relapse."
Rationale: Methadone is an opioid agonist that blocks the effects of opioids by occupying their receptors and preventing them from binding. This reduces the risk of overdose and relapse by eliminating the reward or pleasure of using opioids.
Incorrect choices:
a) "Methadone will help me stop craving opioids.": This is incorrect as methadone does not eliminate cravings for opioids, but it reduces them by preventing withdrawal symptoms.
b) "Methadone will make me feel euphoric like opioids do.": This is incorrect as methadone does not produce euphoria or sedation like opioids do, but it maintains a steady state of opioid tolerance and dependence.
c) "Methadone will cause me to have withdrawal symptoms when I stop taking it.": This is incorrect as methadone prevents withdrawal symptoms by providing a long-acting opioid substitute. However, methadone itself can cause dependence and withdrawal if discontinued abruptly, so it should be tapered off gradually under medical supervision.
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