The nurse is continuing to care for the patient in the emergency department.
Which findings should the nurse identify as potential complications of the client’s diagnostic results? Select all that apply.
Nausea and vomiting
Confusion
Tachycardia
Hypothermia
Amnesia
Respiratory depression
Correct Answer : A,B,E,F
Choice A:
GHB (gamma-hydroxybutyric acid) is known to cause nausea and vomiting, especially at higher doses. These symptoms are common side effects of GHB ingestion and can be distressing for the patient.
Choice B:
Confusion is a significant complication associated with GHB use. GHB acts as a central nervous system depressant, leading to altered mental status and confusion. This can impair the patient’s ability to communicate effectively and understand their surroundings.
Choice C:
Tachycardia, or an abnormally fast heart rate, is not typically associated with GHB use. GHB tends to cause bradycardia (slowed heart rate) rather than tachycardia. Therefore, this option is not a correct answer.
Choice D:
Hypothermia, or abnormally low body temperature, is not a common complication of GHB use. GHB does not typically affect body temperature regulation in a way that would lead to hypothermia. Thus, this option is not a correct answer.
Choice E:
Amnesia is a well-documented effect of GHB, often referred to as the “date rape drug” due to its ability to cause memory loss1. This can result in the patient having no recollection of events that occurred while under the influence of the drug.
Choice F:
Respiratory depression is a severe and potentially life-threatening complication of GHB use. GHB can depress the central nervous system to the point where breathing becomes slow and shallow, which can lead to respiratory failure5. This is a critical concern in managing patients who have ingested GHB.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Implementing seizure precautions is a critical intervention for a client with a history of alcohol use disorder who is admitted while intoxicated. Alcohol withdrawal can lead to seizures, which can be life-threatening. Seizure precautions include maintaining a safe environment, having emergency medication and equipment ready, and monitoring the client closely for signs of seizure activity.
Choice B reason:
Monitoring for orthostatic hypotension is important, especially if the client is experiencing withdrawal symptoms, as dehydration and electrolyte imbalances can occur. However, it is not as immediately critical as implementing seizure precautions for a client who is currently intoxicated.
Choice C reason:
Administering methadone hydrochloride is not an appropriate intervention for alcohol intoxication or withdrawal. Methadone is used for opioid use disorder, not alcohol use disorder, and could be harmful if given to a client with alcohol intoxication.
Choice D reason:
Acidifying the client's urine is not a standard intervention for alcohol intoxication or withdrawal. This intervention is more commonly associated with managing certain drug overdoses or poisonings to increase the elimination of the substance.
Correct Answer is A
Explanation
Choice A reason:
Suppression is a conscious defense mechanism where an individual intentionally avoids thinking about disturbing thoughts or feelings. In this case, the client is choosing to delay addressing the reality of their diagnosis until after a significant family event. This can be seen as a temporary coping strategy to manage overwhelming emotions, but it may become maladaptive if overused or if it prevents the client from seeking necessary treatment and support.
Choice B reason:
Compensation involves overachieving in one area to make up for deficiencies in another. The client's statement does not suggest that they are trying to compensate for their illness by excelling in other areas of life; rather, they are postponing the emotional processing of their diagnosis.
Choice C reason:
Regression is a return to earlier stages of development and coping strategies, often under stress. The client's statement does not indicate a regression to more childlike behaviors or earlier developmental stages.
Choice D reason:
Sublimation is a way of channeling unacceptable impulses into socially acceptable actions. The client's statement does not reflect the use of sublimation, as they are not redirecting their feelings about the diagnosis into a different, more acceptable outlet.
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