Which assessment finding is most important in determining nursing care of a client withdrawing from cocaine?

Facial burns

Perforated septum

Suicide precautions

Nutritional support

Answer and Explanation

The Correct Answer is C

A. Facial burns: Facial burns may occur with methods of drug use, such as smoking crack cocaine, but they are not the most urgent concern during withdrawal. Physical injuries are important but do not guide immediate safety-related nursing priorities.
B. Perforated septum: A perforated nasal septum results from chronic intranasal cocaine use. While it indicates long-term damage, it is not a critical issue during the acute withdrawal phase and does not require urgent intervention.
C. Suicide precautions: Cocaine withdrawal is often associated with severe depression, anxiety, and suicidal ideation. Suicide precautions are essential because of the high risk for self-harm, making this the top priority in nursing care.
D. Nutritional support: Cocaine users may suffer from malnutrition due to poor appetite and lifestyle, but nutritional support is not the immediate concern during withdrawal. Safety and mental health monitoring take precedence.

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Correct Answer is D

Explanation

A. Transfer the client to the emergency department: Transferring the client delays immediate airway management, which is critical. This action is not appropriate as the first step because airway patency must be addressed on the spot to prevent respiratory distress.
B. Call for the registered nurse to reinsert the tube: While notifying the RN is important, maintaining the airway takes precedence. Waiting for another provider before taking action risks closure of the stoma and airway compromise.
C. Cover the tracheostomy site with a sterile gauze to prevent infection: Covering the site without maintaining patency could cause the stoma to close rapidly. Infection control is important, but it is secondary to preserving the airway.
D. Place a dilator in the stoma to maintain the opening: Inserting a tracheostomy dilator prevents the stoma from closing and buys time for reinsertion of the tube. This is the immediate priority to ensure the airway remains open and the client can breathe effectively.

A. Being present without speaking B. Presenting the reality of the situation C. Allowing the client freedom in a confined area D. Speaking in slow, brief sentences

Correct Answer is B

Explanation

A. Being present without speaking: Remaining quietly present can be grounding and non-threatening to disoriented clients. It helps establish a calming environment and builds trust without increasing sensory input.
B. Presenting the reality of the situation: Confronting a disoriented or psychotic client with reality may escalate agitation and aggression. Challenging their perception can feel threatening and lead to increased resistance or hostility.
C. Allowing the client freedom in a confined area: Providing limited autonomy in a safe space can reduce feelings of powerlessness. It supports de-escalation by allowing the client some control while ensuring safety.
D. Speaking in slow, brief sentences: Clear, simple communication helps reduce cognitive overload in disoriented clients. It decreases anxiety and supports comprehension, making it a key strategy in managing agitation.

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Which assessment finding is most important in determining nursing care of a client withdrawing from cocaine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?

Correct Answer is D

Explanation

The nurse is caring for a client with a disturbance in thought process who is disoriented and aggressive. What nursing action may produce further agitation?

Correct Answer is B

Explanation

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