Asked by Melissa Preston on May 08, 2024
Verified
A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/minute
0400: 126/80 mm Hg and 76 beats/minute
0600: 128/82 mm Hg and 72 beats/minute
0800: 132/88 mm Hg and 80 beats/minute
1000: 148/94 mm Hg and 96 beats/minute
What is the nurse's priority action?
A) Force fluids.
B) Begin the detox protocol.
C) Obtain a clean-catch urine sample.
D) Place the patient in a vest-type restraint.
Detox Protocol
A detox protocol is a medically supervised plan designed to safely eliminate toxic substances from the body, often used in the context of substance abuse treatment to manage withdrawal symptoms.
Blood Pressure
The pressure exerted by circulating blood upon the walls of blood vessels, a critical indicator of cardiovascular health.
- Recognize the critical priorities in the examination and intervention of individuals with substance overdose.
- Establish key nursing goals for patients affected by opioid intoxication and decreased respiratory function.
Verified Answer
JI
Joseph ibrahim khaleMay 14, 2024
Final Answer :
B
Explanation :
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.
Learning Objectives
- Recognize the critical priorities in the examination and intervention of individuals with substance overdose.
- Establish key nursing goals for patients affected by opioid intoxication and decreased respiratory function.
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