NUR 211 Test #2

What additional intervention may be needed for the patient experiencing CNS depressant overdose?

IV EKG Telemetry Give antidote Monitor VS

When would the client have tuberculin skin test with purified protein derivative (PPD) read?

48 to 72 hours

Which clinical manifestations is associated with a diagnosis of tuberculosis?

Anorexia, Hemoptysis, Night Sweats

A patient who has a history of misuse of a barbiturate is hospitalized. The nurse monitors for which clinical manifestations that could be attributed to withdrawal from this medication?

Anxiety, Seizures Delirium

Substance Abuse Nursing Care

Ask about the substance: (Name, route, when taken, amount) For toxicity: Address ABC's, suicide risk, safety Use therapeutic communication—be nonjudgmental Hospitalized clients/During withdrawals: o Monitor closely o May need to be on seizure precautions o Frequent vital signs o Client may hallucinate/have delusions o Decrease stimuli during acute withdrawals, quiet and nonstimulating environment Monitor nutritional status. Involve the family: Assess how addiction has affected the family Referrals to community resources o Alcoholics Anonymous, Narcotics Anonymous § In 12 step programs clients must admit to addiction

A patient with pinpoint pupils, shallow respirations, involuntary eye movements, and BP of 90/70 mm Hg is administered flumazenil. The nurse suspects that the patient is abusing which substance?

Benzodiazepine

Chlordiazepoxide

Benzodiazepine Long acting

Lorazepam

Benzodiazepine Short acting

IV Trochlear

Downward and inward eye movement

3 Oculomotor

Eye movement Pupil constriction

What medication is used to treat benzodiazepine overdose?

Flumazenil

Cannabis Withdrawal S/S

Irritability Insomnia Anorexia Cramping Mild agitation

Alcohol Use Nursing Interventions

Promote safety Prevent injury and seizures Promote coping skills Resources on rehabilitation Promote nutrition

Bupropion

Reduces urge to smoke and helps with weight gain S/E: insomnia, dry mouth, irritability, rash, tremors, anorexia, may cause neuropsychiatric problems and increase risk of suicide

Depressant Complications

Respiratory Depression CNS Depression

The nurse manager suspects that a staff nurse has a problem with substance abuse. Which manifestations might the manager notice?

The nurse is often late for work. The nurse appears fatigued and uses mouthwash frequently during work hours. Other staff members report that the nurse has frequent mood changes.

What medication do you administer to prevent Wernicke-Korsakoff syndrome?

Thiamine

A patient who reports using an illicit drug states, "Compared to the past, it seems like I need a larger dose to get the same effect." How will the nurse document the patient' s usage?

Tolerance

Tx for Alcohol Withdrawal Delirium

Benzodiazepines Antipsychotics Anti-seizure meds Chlordiazepoxide- helps agitation caused by withdrawal

Alcohol taken with aspirin increases the risk of what complication?

Bleeding

The company transported an unconscious construction worker, who fell off the roof of a two-story, to the hospital. Which clinical finding would the nurse report immediately?

Bleeding from the ears

1 Olfactory

Sense of smell

Nicotine Gum

30 min regimen with periods of holding gum between cheek and teeth

Tx for Stimulant Use

Lorazepam, Ativan, Diazepam

Which assessment would the nurse perform specific to the safe administration of intravenous mannitol?

Urine output hourly

XI Spinal Accessory

Neck and shoulder muscles

Which information does the nurse include when providing smoking cessation education for a patient?

Use a nicotine-replacement agent. Rid the environment of tobacco products. Call an ex-smoker when the urge to smoke occurs.

The nurse recognizes that a patient with a history of chronic alcohol abuse is at risk for which complication?

Wernicke-Korsakoff syndrome

The nurse anticipates which health problems in a patient who snorts drugs?

Nasal sores, Septal necrosis, Septal perforation

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and would contact the pediatrician to question which prescription?

Nasotracheal suction as needed

Do inhalants reach the CNS slowly or quickly?

Quickly Brief period of euphoria Damaging to parts of the brain

A patient who is withdrawing from heroin experiences diarrhea. The nurse anticipates that which medication will be prescribed?

Loperamide

Which drug is prescribed to stabilize vital signs and prevent seizures and delirium in a patient withdrawing from alcohol?

Lorazepam

Varenicline

May cause neuropsychiatric symptoms and increase risk of suicide S/E: Nausea, sleep disturbances, constipation, flatulence, vomiting, and headache

TBI Assessment Findings

Assess for signs and symptoms. ABC's Glasgow coma scale Level of Consciousness Vital signs Pupils Cranial Nerves Cushing's triad Palmar drift Bruising and lacerations Positive Babinski reflex Rhinorrhea/Otorrhea Vomiting Seizures Uninhibited sexual expression Posturing Paralysis Spasticity, rigidity, flaccid Hyperthermia

A 5-year-old child arrives at the emergency department, and the child's parents state that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia

Pathophysiology of ICP

Brain injury can cause growing pressure inside the skull, which can injure the brain/spinal cord

Which antidepressant medication approved by the Food and Drug Administration (FDA) is a smoking cessation aid that can help a patient adhere to a plan to quit smoking?

Bupropion

The nurse is reviewing the record of a child with increased intracranial pressure from a head injury and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

Nicotine Patch

Rotate Sites Provides steady nicotine release Avoid adhesive allergies

After establishing ABC priorities, what is a primary nursing concern for the patient with alcohol toxicity?

Safety

Which finding would the nurse immediately report to the health care provider of a client prescribed rifampin after being exposed to active TB?

Small, red, pinpoint areas on the arms

Which education would the nurse provide for a patient who receives a prescription for nicotine lozenges?

"Avoid taking this medication with food."

What is the Glasgow coma score for a client who opens the eyes when their name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus.?

11

Which treatment measure would the nurse reinforce as the highest priority when providing discharge teaching to a client with TB?

Consistently taking prescribed medication

VIII Vestibulocochlear

Hearing and balance

When assessing a client with a diagnosed "brain attack" (cerebrovascular accident [CVA]), the nurse evaluated the baseline vital signs of pulse rate of 78 beats per minute (bpm) and a blood pressure (BP) of 120/80 mm Hg. Which changes in the baseline vital signs indicate an increasing intracranial pressure (ICP)?

Pulse 50 bpm and BP 140/60 mm Hg

X Vagus

Swallowing Speaking Cough Facial expressions

What is Cushing's triad?

Systolic BP is high Bradycardia Decreased respirations

Which statement indicates that a female client who is receiving rifampin for tuberculosis understands the teaching?

"This medication may be hard on my liver, so I must avoid alcoholic drinks while taking it." "This medication may reduce the effectiveness of the oral contraceptive I am taking. "My health care provider must be called immediately if my eyes and skin become yellow."

For a client, admitted to the hospital after an accident, the nurse uses the Glasgow Coma Scale (GCS). The client is alert and opens eyes when there is a sound or when someone talks. When asked questions, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. Which total client score would the nurse document?

13

Depressant Nursing Interventions

Assessing airway, breathing, and oxygenation Monitor for respiratory distress Administer naloxone as ordered Cardiac monitor

Lozenge

Avoid food or drink

Which possible cause would the nurse suspect in a client with a head injury who has a fixed, dilated right pupil, responds only to painful stimuli, and exhibits flexion (decorticate) posturing?

Cerebral compression

V Trigeminal

Chewing Facial Sensation

Alcohol Complications

Cirrhosis Immune system depression Heart disease Higher chance of cancer Alcohol withdrawal syndrome

Which potentially life-threatening client condition found during the primary triage survey would necessitate priority nursing care?

Concussion

TB Isoniazid

Decreased B6 levels- anemia, glossitis, rashes, mental status changes Neurotoxicity- headache, confusion, limb weakness and numbness Nurse Considerations: Monitor for peripheral neuropathy, tired, irritable, depressed

What will pupils look like with stimulant toxicity?

Dilated

Antabuse

Given to patient wishing to abstain from alcohol If a patient takes alcohol while on antabuse they will have flushing, sweating, nausea, severe vomiting, throbbing headache, chest pain, faint

ICP When to Notify the Provider

Increased drowsiness- difficulty arousing and confusion Nausea/ Vertigo Worsening headache/ Stiff neck Seizures Vision difficulties- blurred vision, light sensitivity Behavioral changes- anger/ irritation Motor Problems- difficulty walking Slurred speech Clumsiness HR less than 60

A patient is admitted to the emergency department with a suspected history of cocaine use. The nurse expects to find which physiologic changes?

Increased heart rate, Increased BP

Withdrawal from sedative hypnotics can be life threatening. Tx includes?

Long acting benzodiazepine in a tapered dose Implement safety measures Check VS Provide orientation

Smoking Complications

Periodontal disease Cardiovascular disease Cancer (mouth, cheek, tongue, throat, esophagus) Lung disease (COPD, emphysema, cancer) Blood clots Hypertension

Which clinical finding would the nurse recognize as a sign of neurologic injury when assessing a 7-month-old infant injured in an automobile collision

Persistent vomiting

What will a patients pupils look like on depressants?

Pinpoint

Which action would the nurse take when an older adult who was in a motor vehicle collision exhibits a decreased level of consciousness and serosanguineous drainage from the left ear?

Place a sterile pad over the external ear.

Which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for TB?

Place the client on airborne precautions

Which medication would the nurse consider is causing difficulty hearing in a client with a history of tuberculosis?

Streptomycin

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. in the plan of care, the nurse identifies seizure precautions and documents that which items) needs to be placed at the child's bedside?

Suctioning equipment and oxygen

Which instruction would the nurse give the client when assessing for damage to the glossopharyngeal and vagus nerves?

Swallow

Which instruction by the nurse will be beneficial to the client prescribed isoniazid for tuberculosis?

You should take the medication on an empty stomach

Which room assignment would the nurse select for a child hospitalized with newly diagnosed TB?

Isolation room

Smoking Tx

Patch Lozenges Gum Inhaler Nasal sprays Varenicline Bupropion

What is priority intervention for depressant toxicity?

Patent airway

2 Optic

Vision

TB Streptomycin

Watch out for tinnitus, ototoxicity, neurotoxicity, and nephrotoxicity Still used for TB but is not the first line of therapy anymore Used to treat pts who cannot undergo the first line standard therapy due to drug-resistant Mycobacterium tuberculosis Given to patients that cannot take some of the first line meds due to being pregnant or breastfeeding, take in place of whichever drug they cannot take

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, which information about the client would the nurse obtain?

Whether the result of an earlier tuberculin test was positive

Which nursing action would the nurse implement immediately when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale (GCS) score of 7?

Prepare for intubation

Behavioral Indicators that suggesting substance abuse

Presence of mental disorders increases risk for substance abuse Overuse of mouthwash and toiletries Citations while driving Trauma due to falls/accidents Financial problems Defensive Social problems- marriage, job changes/absenteeism, estranged from family and friends

IX Glossopharyngeal

Tongue movement Swallowing Taste

Alcohol Withdrawal S/S

Tremors BP 150/100 Pulse 120 RR 22 Temp 100F Diaphoretic Delirium- Picking at "bugs" on his bed Changes in LOC- Alternately confused and lucid Risk for seizures Insomnia- Hasn't slept in 2 days. Agitation Recently lost his job Wife left him

TB Patient Education

Advise patient that they're no longer contagious after 2-3 weeks of starting therapy Smoking cessation if patient smokes Cover nose and mouth with tissue when producing sputum, wear surgical mask when outside of negative pressure room, use proper hand hygiene After 2-3wks of treatment a sputum culture is needed every 2-4wks with a neg. result Restrict visitors, stay in separate rooms from other family members and home should be well-ventilated Be sure medication therapy is completed and taken as directed. Medication is taking for up to 12 months. Teach side effects of medications.

The nurse is assessing a patient in the emergency department and suspects cocaine overdose based on which clinical manifestations?

Agitation, Cardiac dysrhythmias

Which educational statement from the nurse will be beneficial for the client with TB?

Avoid exposure to any inhalation irritants. Eat foods that are rich in protein and vitamins C and B. Cover the mouth and nose with a tissue when coughing or sneezing

What assessment findings related to blood pressure, heart rate, and temperature are associated with stimulant toxicity/overdose? What interventions should the nurse implement based on these findings?

BP, HR, temp will be elevated -Cooling blanket -EKG -Telemetry -Nitrates -Calcium channel blockers -Establish IV -Risk for seizures: give diazepam or lorazepam

Glasgow Coma Scale (GCS)

Best Response- 15 Comatose Client- 8 or less Totally unresponsive- 3

Which component of the Glasgow Coma Scale (GCS) assessment tool would the nurse recall when performing a neurological assessment on a client?

Best motor response, Best eye-opening response, Best verbal response

The nurse reviews the medical record of a patient who chronically misuses alcohol and expects which laboratory results associated with the patient's diagnosis of Wernicke-Korsakoff syndrome?

Decreased thiamine level

Alcohol Withdrawal Nursing Interventions

Delirium prevention Fluid and electrolyte balance Pharmacologic support Psychological support Nutritional support Safety

The nurse should take which infection control measure when caring for a client admitted with a tentative diagnosis of infectious pulmonary TB?

Don an N95 respirator mask before entering the room

Which mechanism of action is responsible for the therapeutic effects of mannitol precribed for a client with a head injury?

Drawing fluid from brain cells into the bloodstream

Depressant Tx

Naloxone

What manifestations can occur as a result of large amounts of caffeine?

Tachycardia Cardiac dysrhythmias Hypertension Disturbed sleep Anxiety Seizure

The nurse is teaching a client with a diagnosis of pulmonary TB about recovery after discharge. Which is the most important intervention for the nurse to include in this plan?

Taking medication as prescribed

Which patient behavior indicates that substance misuse relapse has occurred?

The patient returns to substance use after a period of abstinence.

An informed consent has not yet been obtained for an unconscious client scheduled for surgery. Which course of action does the nurse expect to be taken to deal with the situation?

The surrogate decision maker designated by the client will give consent.

XII Hypoglossal

Tongue movement Swallowing Speech

The nurse obtains a laboratory report that shows acid-fast rods in a clients sputum. Which disorder would the nurse consider may be related to these results?

Mycobacterium Tuberculosis

A patient is receiving oxycodone therapy. The patient's assessment findings include involuntary eye movements, shallow respirations, BP of 90/70 mm Hg, and oxygen saturation of 85%. The nurse identifies that which medication will be beneficial to the patient?

Naloxone

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client?

Negative airflow room

A patient who is planning to quit smoking is prescribed varenicline. Which symptoms should the nurse instruct the patient to report to the health care provider?

Agitation, Depression, Suicidal thoughts

TB Transmission/PPE/Protection

Airborne Precautions- N-95, gloves, gown, put patient in negative pressure isolation room and cluster care Hand hygiene and cover mouth and nose when cough/sneeze Tested for TB 6 months after exposure to a positive

TB Rifampin

Bodily fluids orange- sweat, tears, urine, Photosensitivity Liver problems- jaundice will appear in eyes first Nurse Considerations: Educate on orange body fluids, Photosensitivity- sunscreen, stay indoors & away from windows, covering clothing, Assess for jaundice

ICP Mannitol

Monitor fluid and electrolyte status) Given by IV infusion slowly (0.25-2g/kg over 30-60mins), undiluted Reduces the risk of fluid overload

ICP Corticosteroids

Monitor fluid intake, sodium and glucose levels, concurrent antacids, and proton pump inhibitors

Stimulant Complications

Dysrhythmias Myocardial infarction Stroke Hypertension Respiratory Distress Seizures

Which psychologic or physiologic effects does the nurse anticipate in a patient addicted to opioids?

Euphoria, Drowsiness, Mood changes

VII Facial

Facial expressions Taste

Which cranial nerves assist with both sensory and motor function?

Facial, Trigeminal

Which clinical manifestations is associated with TB?

Fatigue, Nausea, Low-grade Fever

After receiving a dose of lorazepam, a patient experiences respiratory depression. Which medication will the nurse plan to administer?

Flumazenil

After collecting data from a patient, the nurse determines that the patient is experiencing the effects of crack cocaine withdrawal. Which set of clinical manifestations supports the nurse's conclusion?

General aching, vivid dreams, mood swings, and increased appetite

Types of Inhalants

Glue Paint Aerosol cleaners

Which action would the nurse take when a client complains of a headache and drowsiness after an automobile collision while being oriented to person and place but confused to time with pupils equal and reactive?

Monitor the client for increasing intracranial pressure.

The nurse is caring for a 10-year-old child who sustained a blunt head injury when accidentally hit with a baseball bat. The child exhibits a significant decrease in level of consciousness, bradycardia, and decorticate posturing. The child is at risk for seizures, and the nurse creates a plan of care to initiate seizure precautions; the plan includes the following actions?

Have suction equipment and oxygen available. Raise the side rails on the bed. Pad the side rails and other hard objects. Clear the area of any hazards or hard objects. Place a waterproof mattress or pad on the bed. Alert caregivers to the need for seizure precautions or any other special precautions.

Stimulant Use S/S

Heart Palpitations Hypertension Tachycardia Euphoria Alertness Energy boost Restlessness Hypervigilant Agitation Delirium Impaired judgment Paranoia

Alcohol Withdrawal What to Monitor For

Hypertension Stroke Digestive problems Seizures Agitation Anxiety Potential violence Wernicke-Korsakoff Syndrome

The nurse completes an admission assessment of a patient who is hospitalized with a new onset of heart palpitations. The patient states, "I consumed a highly caffeinated energy drink right before my symptoms began." Which additional clinical manifestations is the nurse most likely to observe?

Hypertension and anxiety

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue?

Hypoglossal

ICP Nutritional Therapy

Increased need for glucose, enteral or parenteral nutrition Early feeding (within 3 days of injury)

Pathophysiology of TB

Infectious disease caused by Mycobacterium Tuberculosis which normally involves the lungs but any organ can be infected. Once inhaled, the particles will lodge into the bronchioles and alveoli. It is aerophilic -Oxygen loving! Starts as a latent infection and can later turn into active TB. Symptoms: Cough lasting more than 3 weeks, chest pain, hemoptysis, fatigue, night sweats, weight loss, chills, fever

Alcohol Use S/S

Insomnia Lethargy Slurred speech Tremors Excessive napping Inability to focus Weight loss

Depressant Withdrawal S/S

Intense drug craving Diaphoresis GI distress- diarrhea Restlessness, fever Insomnia Watery eyes Tremors Muscle aches Runny nose-rhinorrhea Anxiety

Tobacco Withdrawal S/S

Irritable Tired Anxious

Pathophysiology of TBI

Is a serious injury or trauma to the scalp, skull, or brain. Resulting in mild to extensive damage to the brain

Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer?

Lethargy

Which finding during the assessment of a child after a shunt procedure to correct increased intercranial pressure is of most concern?

Marked irritability

ICP Nursing Interventions

Monitor IV fluids Daily Electrolytes Monitor for DI and SIADH Elevate HOB 30 degrees Avoid hip flexion Prevent extreme neck flexion Avoid coughing, straining, and valsalva Turn slowly Seizure precautions Quiet, nonstimulating environment Judicious use of restraints and sedatives Maintain patent airway Monitor ABGs Maintain ventilatory support Keep head and neck midline

ICP Patient Education

No oropharyngeal suctioning Be compliant with HTN medications No hot baths Avoid extreme weather that will raise or lower body temperature Check with HCP before taking drugs that may increase drowsiness Abstain from alcohol, caffeine and nicotine Avoid driving and use of heavy machinery Stay hydrated Eat small frequent meals/snacks with carbs and protein Maintain HOB elevated at 30 degrees Maintain neck in neutral position Don't play contact sports until cleared by HCP Rest your body Take days off of work and school Limit screen time and loud music Avoid stressful situations Avoid reading Sleep in a dark room Keep a fixed bedtime and wake up schedule

After a client at an outpatient clinic has been diagnosed with active tuberculosis, which action by the nurse is best?

Notify the local public health department of the new diagnosis

Stimulant Withdrawal Symptoms

Often not life threatening, client will report cravings for the drug

An overdose of which substance causes pinpoint pupils, nystagmus, and hypotension?

Opioid

TB Procedures

PPD Test -Positive in all people regardless if >15 mm induration -Inject intradermally in forearm -Assess for induration in 48-72 hours Interferon gamma release assays blood test -Results in a few hours Chest X-ray -Abnormal Sputum is the gold standard for diagnosis of TB -3 consecutive sputum cultures 8-24 hour intervals, in the morning is best time

Which physiologic effects are likely to be observed in a patient after methamphetamine abuse?

Palpitations, Sleeplessness, Increased temperature

VI Abducens

Parallel eye movement

Which prescription found in the treatment plan of a client who has increased intracranial pressure and is unconscious with a heart rate of 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg would a nurse question?

Morphine

Which statement by a client with TB indicates the need for further teaching after receiving instructions regarding isoniazid therapy?

I should apply sunscreen and wear sun protective clothing while going outside

Which statement made by a client prescribed Isoniazid as a prophylactic measure due to having a spouse with active TB indicates that there is a need for further teaching?

I sometimes allow our children to sleep in our bed at night. I know I also have TB because the skin test was positive. I plan to attend a wine tasting event this evening.

Which statement by the client indicates to the nurse a need for further teaching on isoniazid therapy?

I will stop treatment once my fever has subsided

When caring for a patient with acute intoxication and a history of chronic alcoholism, the nurse anticipates a prescription for which drug?

IV thiamine

Which intervention would the nurse recommend to decrease tuberculosis (TB) in the community?

Improving financial resources. Eliminating overcrowded housing. Initiating needle-sharing programs. Improving access for food pantries. Providing barrier contraceptive devices.

In which position would a nurse maintain a client who has experienced a subarachnoid hemorrhage?

In bed with the head of the bed elevated

ICP Hypertonic Saline

Moves water out of cells and into bloodstream Monitor BP and sodium levels

Which statement made by a client with tuberculosis started on rifampin indicates effective teaching?

My sweat will turn orange from this medication

ICP Assessment Findings

Raccoon eyes Rhinorrhea (Runny nose) Battle's sign (bruising behind the ear) CSF leak from ears or nose Change in LOC Headache Projectile Vomiting- not preceded by nausea Cushing's Triad- systolic B/P high, bradycardia decrease RR Pupil Changes Impaired eye movement

Can you drink alcohol on a antidepressant?

No it increases the effect of the drug. increases CNS depression

Which nursing action is appropriate for a patient during the tonic-clonic stage of a seizure?

Protect the client's head from injury

What condition can occur as result of acute marijuana toxicity?

Psychotic episodes

Tx for Alcohol Withdrawal

Seizure Precautions VS every 2 hours Benzodiazepines Magnesium Thiamine Multivitamins IV glucose Alpha or beta blockers

A patient receives IV diazepam to treat alcohol withdrawal. The nurse recognizes that the medication is prescribed to prevent which medical condition?

Seizures

Which response would a nurse give to a client with TB who takes combination therapy with isoniazid, rifampin, pyrazinamide, and streptomycin who makes the statement "I've never had to take so much medication for an infection before"?

The bacteria causing this infection are difficult to destroy