- A 31-year-old client is admitted to an inpatient psychiatric unit after using methamphetamine for several days; the client reports no sleep for 3 nights. The client is pacing, yelling at staff, and appears paranoid; vital signs: temperature 37.2°C (99.0°F), heart rate 132/min, blood pressure 168/96 mm Hg, respiratory rate 24/min; mental status: alert, hypervigilant, and aggressive; labs: creatine kinase 420 U/L (normal 30–200 U/L). Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Use calm verbal de-escalation, maintain safety, and reduce environmental stimulation
This question tests nursing interventions and clinical judgment related to substance use, specifically methamphetamine intoxication management. The priority concern is the client's acute agitation, paranoia, and aggressive behavior combined with sympathetic overstimulation (tachycardia, hypertension, elevated CK) that poses immediate safety risks to self and others. Using calm verbal de-escalation, maintaining safety, and reducing environmental stimulation (B) is the best choice because it addresses the immediate behavioral crisis while avoiding physical confrontation that could escalate violence. Encouraging oral fluids and meals (A) ignores the acute behavioral emergency, nicotine patches (C) are irrelevant to methamphetamine intoxication, and completing a detailed assessment (D) is premature when the client is acutely agitated and paranoid. The underlying principle is that stimulant intoxication causes hypervigilance, paranoia, and potential violence requiring immediate de-escalation and environmental management before any other interventions. The transferable nursing strategy is to approach stimulant-intoxicated clients calmly, reduce sensory stimulation, maintain safe distances, and use verbal techniques while having backup readily available for safety.
- A 48-year-old client hospitalized for pneumonia has a history of drinking 8–10 beers nightly and last drank 12 hours ago. The client is tremulous, diaphoretic, and reports anxiety; vital signs: heart rate 112/min, blood pressure 162/90 mm Hg, temperature 37.6°C (99.7°F); mental status: oriented, irritable; labs: glucose 68 mg/dL (normal 70–110). The nurse should PRIORITIZE which action for the client experiencing withdrawal?
Answer: Administer the prescribed benzodiazepine based on withdrawal severity scoring and recheck vital signs frequently
This question tests nursing interventions and clinical judgment related to substance use, particularly alcohol withdrawal in a comorbid condition. The priority concern is the client's tremors, diaphoresis, anxiety, tachycardia, hypertension, and hypoglycemia, indicating moderate withdrawal risk. Administering benzodiazepines based on severity scoring is the best choice as it targets symptoms and prevents progression, referencing the vital signs and low glucose. Nicotine patch is unrelated; dietary history is not immediate; disulfiram is for maintenance. The underlying principle of care in substance use scenarios is symptom-triggered pharmacotherapy to minimize over-sedation. Correcting electrolytes and glucose is essential to avoid complications. A transferable nursing strategy is to integrate withdrawal management with treatment of the primary condition, like pneumonia.
- A 31-year-old client is brought to the emergency department after suspected fentanyl use. The client is cyanotic with respiratory rate 5/min, oxygen saturation 80% on room air, heart rate 58/min, blood pressure 104/60 mm Hg; pupils are pinpoint; mental status: unresponsive to voice. Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Administer naloxone per protocol and provide ventilatory support while preparing for possible repeat dosing
This question tests nursing interventions and clinical judgment related to substance use, responding to opioid overdose. The priority concern is the client's cyanosis, bradypnea, hypoxia, bradycardia, hypotension, pinpoint pupils, and unresponsiveness, indicating severe respiratory depression. Administering naloxone with ventilatory support is the best choice as it reverses effects quickly, addressing the low saturation and rate. IV fluids alone ignore reversal; consent delays emergency care; low stimulation is insufficient for apnea. The underlying principle of care in substance use scenarios is rapid antidote administration in life-threatening overdoses. Preparation for intubation may be needed if no response. A transferable nursing strategy is to train laypersons in naloxone use for community overdose prevention.
- A 37-year-old client on a psychiatric unit with known methamphetamine use is restless and complains of chest tightness. Vital signs: heart rate 138/min, blood pressure 182/108 mm Hg, respiratory rate 26/min, oxygen saturation 95% on room air; mental status: anxious, paranoid; labs: troponin pending (normal <0.04 ng/mL). Which assessment finding requires IMMEDIATE attention?
Answer: Chest tightness with blood pressure 182/108 mm Hg and heart rate 138/min
This question tests nursing interventions and clinical judgment related to substance use, recognizing cardiovascular risks in stimulant use. The priority concern is the client's restlessness, chest tightness, tachycardia, hypertension, anxiety, and paranoia, suggesting possible myocardial ischemia. Chest tightness with blood pressure 182/108 mm Hg and heart rate 138/min requires immediate attention as it indicates hypertensive emergency and cardiac strain. Anxiety is symptomatic; normal saturation less urgent; history contextual. The underlying principle of care in substance use scenarios is prompt evaluation of chest pain in sympathomimetic toxicity. ECG and troponin testing are essential. A transferable nursing strategy is to administer benzodiazepines for agitation while ruling out medical causes.
- A 52-year-old client admitted for pancreatitis reports drinking "a fifth of vodka daily" for years and had the last drink 10 hours ago. The client is diaphoretic and anxious with coarse tremors, nausea, and insomnia; vital signs: temperature 37.2°C (99.0°F), heart rate 118/min, blood pressure 176/98 mm Hg, respiratory rate 22/min, oxygen saturation 97% on room air; mental status: oriented but restless and easily startled; labs: magnesium 1.3 mg/dL (normal 1.7–2.2), potassium 3.2 mEq/L (normal 3.5–5.0). Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Institute seizure precautions and administer the prescribed benzodiazepine per alcohol-withdrawal protocol
This question tests nursing interventions and clinical judgment related to substance use, specifically recognizing and managing alcohol withdrawal syndrome. The priority concern is the client's symptoms of diaphoresis, anxiety, tremors, nausea, insomnia, tachycardia, hypertension, and electrolyte imbalances, indicating severe alcohol withdrawal with risk for seizures and delirium tremens. Instituting seizure precautions and administering benzodiazepines per protocol is the best choice because the client's elevated heart rate, blood pressure, and low magnesium and potassium levels increase seizure risk, requiring immediate stabilization. Requesting disulfiram is incorrect as it is for aversion therapy post-detox, not acute withdrawal; obtaining a timeline is important but not immediate; naloxone is for opioids, not alcohol, which is a common misconception in mixed substance cases. The underlying principle of care in substance use scenarios is to prioritize physiological stability and prevent life-threatening complications like seizures or cardiovascular events. Additionally, electrolyte correction and thiamine administration are essential to avoid Wernicke-Korsakoff syndrome. A transferable nursing strategy is to use standardized tools like CIWA-Ar for ongoing assessment and symptom-triggered interventions in withdrawal management.
- A 41-year-old client in a community clinic reports smoking 2 packs/day for 20 years and quit 2 days ago. The client reports intense cravings, irritability, difficulty concentrating, and insomnia; vital signs: heart rate 88/min, blood pressure 132/78 mm Hg; mental status: anxious but cooperative; labs: none abnormal. Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Offer nicotine replacement therapy and teach correct use while assessing readiness to quit and triggers
This question tests nursing interventions and clinical judgment related to substance use, emphasizing nicotine withdrawal management. The priority concern is the client's intense cravings, irritability, concentration issues, and insomnia after abrupt cessation of heavy smoking, indicating nicotine dependence. Offering nicotine replacement therapy with teaching on use and triggers is the best choice as it alleviates symptoms and supports quitting, aligned with the client's anxiety and vital signs. Naloxone is for opioids, not nicotine; alcohol-withdrawal scoring is misplaced; starting varenicline without assessment ignores contraindications like psychiatric history. The underlying principle of care in substance use scenarios is to use evidence-based pharmacotherapy and behavioral support for withdrawal. Combining long- and short-acting NRT enhances efficacy for heavy smokers. A transferable nursing strategy is to assess readiness to quit using motivational interviewing and tailor interventions to individual needs.
- A 26-year-old client presents to the emergency department after being found unresponsive; friends report prescription opioid misuse. The client is somnolent with respiratory rate 8/min, oxygen saturation 88% on room air, heart rate 60/min, blood pressure 110/66 mm Hg; pupils are pinpoint; mental status: arouses to painful stimulus. Which assessment finding requires IMMEDIATE attention?
Answer: Respiratory rate 8/min with oxygen saturation 88% on room air
The respiratory rate of 8/min with oxygen saturation 88% on room air is the most immediate threat because it signals severe respiratory depression and hypoxemia, which can lead to respiratory arrest and require urgent airway support and naloxone. The reported history of opioid misuse is a risk factor but is not an acute finding demanding immediate intervention. A heart rate of 60 beats per minute, though bradycardic, is not the priority when breathing is compromised. The blood pressure of 110/66 mm Hg is within normal limits and does not indicate immediate instability. In opioid overdose, airway and breathing take precedence; the respiratory finding is the only one that directly endangers life right now.
- A 33-year-old client is brought to the emergency department for suspected opioid overdose after taking oxycodone with alcohol; the client has a history of opioid misuse. Assessment: respiratory rate 7/min, oxygen saturation 84% on room air, heart rate 48/min, blood pressure 90/50 mm Hg; pupils pinpoint; mental status: minimally responsive to painful stimuli; labs: arterial blood gas shows pH 7.28 (normal 7.35–7.45), PaCO2 58 mm Hg (normal 35–45 mm Hg). Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Administer naloxone per protocol and provide bag-valve-mask ventilation with supplemental oxygen
This question tests nursing interventions and clinical judgment related to substance use, specifically severe opioid overdose with respiratory acidosis. The priority concern is profound respiratory depression (rate 7/min, O2 sat 84%) with respiratory acidosis (pH 7.28, PaCO2 58) indicating inadequate ventilation and imminent respiratory arrest requiring immediate reversal and ventilatory support. Administering naloxone and providing bag-valve-mask ventilation (B) is the best choice because it simultaneously reverses opioid effects and corrects hypoxemia/hypercapnia through assisted ventilation. Collecting urine for toxicology (A) delays life-saving treatment, starting buprenorphine (C) would worsen the overdose as it's a partial opioid agonist, and placing in a quiet environment (D) ignores the critical respiratory failure. The underlying principle is that severe opioid overdose with respiratory acidosis requires both pharmacological reversal with naloxone and mechanical ventilatory support to prevent death from hypoxic brain injury. The transferable nursing strategy is to recognize that severe respiratory depression may require ventilatory support beyond naloxone alone, especially when acidosis is present, and to provide assisted ventilation while administering the antidote.
- A 19-year-old client is seen in a community clinic and reports vaping nicotine daily for 3 years; the client stopped 2 days ago. The client reports intense cravings, irritability, difficulty concentrating, and insomnia; vital signs: temperature 36.8°C (98.2°F), heart rate 92/min, blood pressure 128/78 mm Hg, respiratory rate 16/min; mental status: anxious but cooperative; labs: within expected limits. Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Teach coping strategies and initiate nicotine replacement therapy per clinic protocol
This question tests nursing interventions and clinical judgment related to substance use, specifically nicotine withdrawal management. The priority concern is the client's nicotine withdrawal symptoms (cravings, irritability, insomnia, difficulty concentrating) that began 2 days after cessation, which can lead to relapse without appropriate support. Teaching coping strategies and initiating nicotine replacement therapy (B) is the best choice because it addresses withdrawal symptoms, reduces cravings, and supports successful cessation through evidence-based interventions. Naloxone (A) is for opioid overdose and irrelevant here, obtaining an ECG (C) is unnecessary with normal vital signs and no cardiac symptoms, and disulfiram (D) is for alcohol use disorder, not nicotine dependence. The underlying principle is that nicotine withdrawal, while not life-threatening, requires prompt symptom management and behavioral support to prevent relapse and promote successful cessation. The transferable nursing strategy is to recognize nicotine withdrawal symptoms, provide immediate coping strategies, initiate replacement therapy when appropriate, and offer ongoing support throughout the cessation process.
- A 40-year-old client admitted for abdominal pain has a history of alcohol use disorder and last drank 6 hours ago. The client is anxious with mild tremors; vital signs: heart rate 102/min, blood pressure 150/86 mm Hg; mental status: oriented; labs: glucose 56 mg/dL (normal 70–110). Which assessment finding requires IMMEDIATE attention?
Answer: Glucose 56 mg/dL (normal 70–110)
This question tests nursing interventions and clinical judgment related to substance use, addressing acute complications in alcohol use disorder. The priority concern is the client's anxiety, mild tremors, tachycardia, hypertension, and hypoglycemia, with risk for seizures or altered mental status. The glucose of 56 mg/dL requires immediate attention as alcoholics are prone to hypoglycemia, exacerbating withdrawal. Tremors and anxiety are expected; blood pressure elevated but secondary; history not acute. The underlying principle of care in substance use scenarios is correcting metabolic derangements promptly. Glucose administration follows thiamine to prevent encephalopathy. A transferable nursing strategy is to check blood glucose routinely in withdrawing clients and treat per protocol.
- A 39-year-old client on a psychiatric unit has a history of methamphetamine use and is now refusing care, shouting, and throwing objects. Vital signs: heart rate 128/min, blood pressure 160/96 mm Hg, respiratory rate 22/min, oxygen saturation 98% on room air; mental status: alert, hostile, paranoid; labs: none yet. What is the FIRST action the nurse should take for this client?
Answer: Attempt verbal de-escalation, ensure adequate staff support, and maintain a safe distance with an exit route
This question tests nursing interventions and clinical judgment related to substance use, de-escalating stimulant-induced agitation. The priority concern is the client's refusal of care, shouting, throwing objects, tachycardia, hypertension, hostility, and paranoia, posing safety risks. Attempting verbal de-escalation with staff support and safe positioning is the best choice as it prevents escalation, per the vital signs and behavior. Immediate restraints bypass least-restrictive options; full assessment risks safety; nicotine patch is unrelated. The underlying principle of care in substance use scenarios is non-confrontational approaches in psychotic states. Medications like antipsychotics may follow if needed. A transferable nursing strategy is to document behaviors and interventions for legal protection in behavioral crises.
- A 30-year-old client is admitted to the emergency department after opioid overdose and receives naloxone with improvement. Thirty minutes later the client becomes drowsy again; vital signs: respiratory rate 9/min, oxygen saturation 89% on room air, heart rate 62/min, blood pressure 112/70 mm Hg; mental status: difficult to arouse; labs: none available. Which intervention should the nurse implement IMMEDIATELY?
Answer: Administer an additional dose of naloxone per protocol and support ventilation as needed
This question tests nursing interventions and clinical judgment related to substance use, handling recurrent opioid effects post-reversal. The priority concern is the client's returning drowsiness, bradypnea, hypoxia, bradycardia, and poor arousal 30 minutes after naloxone, indicating renarcotization. Administering additional naloxone with ventilation support is the best choice as it counters the longer opioid half-life, per the declining vital signs. Discharge teaching is premature; med reconciliation secondary; NRT unrelated. The underlying principle of care in substance use scenarios is repeated dosing for potent opioids like fentanyl. Continuous infusion may be needed for prolonged effects. A transferable nursing strategy is to educate on polysubstance risks and observe for hours post-overdose.
- A 26-year-old client is brought to the emergency department after being found unresponsive; friends report heroin use. Assessment findings: respiratory rate 6/min with shallow respirations, oxygen saturation 82% on room air, heart rate 54/min, blood pressure 98/56 mm Hg; pupils are pinpoint; mental status: unresponsive to verbal stimuli; glucose 96 mg/dL (normal 70–110 mg/dL). What is the FIRST action the nurse should take for this client?
Answer: Administer naloxone per protocol and support ventilation as needed
This question tests nursing interventions and clinical judgment related to substance use, specifically opioid overdose management. The priority concern is respiratory depression (rate 6/min, O2 sat 82%) with classic opioid overdose signs (pinpoint pupils, unresponsiveness) requiring immediate reversal to prevent respiratory arrest and death. Administering naloxone and supporting ventilation (A) is the best choice because it directly reverses opioid-induced respiratory depression and restores adequate oxygenation within minutes. Obtaining a urine drug screen (B) wastes precious time when the clinical presentation is clear, placing in a quiet room (C) ignores the life-threatening respiratory depression, and methadone (D) would worsen the overdose as it's an opioid agonist, not an antagonist. The underlying principle is that opioid overdose causes potentially fatal respiratory depression that requires immediate reversal with naloxone, an opioid antagonist, while supporting ventilation. The transferable nursing strategy is to recognize the opioid overdose triad (respiratory depression, pinpoint pupils, decreased consciousness), administer naloxone immediately, and monitor for re-sedation as naloxone's duration is shorter than most opioids.
- A 27-year-old client arrives to the emergency department after an opioid overdose reversed by emergency medical services. The client is now awake but drowsy; vital signs: respiratory rate 14/min, oxygen saturation 96% on room air, heart rate 104/min, blood pressure 138/82 mm Hg; pupils no longer pinpoint; mental status: anxious and nauseated; labs: none available yet. Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Provide continuous respiratory and oxygen saturation monitoring and reassess for recurrent sedation as naloxone wears off.
After an opioid overdose is reversed with naloxone, the client remains at risk for recurrent sedation because the opioid may remain in the body longer than the reversal agent. The immediate priority is continuous respiratory and oxygen saturation monitoring with frequent reassessment of sedation. Seizure precautions are not supported here: there is no evidence of alcohol withdrawal, and the anxiety, nausea, and tachycardia after naloxone are more consistent with opioid withdrawal than with alcohol withdrawal. Collecting a complete substance-use history and administering a depression screen may be useful later, but it is not the urgent step and does not address the risk of renewed respiratory depression. Starting methadone immediately is also incorrect because methadone is a long-term treatment for opioid use disorder, not an emergency post-reversal intervention; giving it before the client is observed may make sedation harder to monitor. Only continuous respiratory monitoring and repeated sedation assessment directly address the risk that naloxone will wear off before the opioid is cleared.
- A 29-year-old client on a psychiatric unit admits to using methamphetamine earlier today and becomes increasingly agitated. The client is sweating and clenching fists; vital signs: temperature 38.1°C (100.6°F), heart rate 140/min, blood pressure 172/104 mm Hg, respiratory rate 26/min; mental status: paranoid and threatening staff; labs: sodium 140 mEq/L (normal 135–145 mEq/L). The nurse should PRIORITIZE which action for the client experiencing stimulant intoxication?
Answer: Approach with a calm, nonthreatening stance, set clear limits, and call for assistance to maintain safety
This question tests nursing interventions and clinical judgment related to substance use, specifically acute methamphetamine intoxication with escalating aggression. The priority concern is the client's paranoid, threatening behavior with sympathetic overstimulation (tachycardia, hypertension, hyperthermia) creating immediate danger to self, staff, and other patients requiring de-escalation and safety measures. Approaching calmly, setting limits, and calling for assistance (A) is the best choice because it prioritizes safety while using therapeutic communication to prevent violence and prepare for potential physical intervention if needed. Starting motivational interviewing (B) is inappropriate during acute intoxication with paranoia, disulfiram (C) is for alcohol not stimulants, and teaching sleep hygiene (D) ignores the immediate safety threat. The underlying principle is that stimulant-induced paranoia and aggression require immediate safety interventions, including team response, before any therapeutic interventions can be attempted. The transferable nursing strategy is to maintain a calm demeanor, ensure adequate backup is available, use clear and simple communication, respect personal space, and be prepared to implement emergency protocols if verbal de-escalation fails.
- A 45-year-old client admitted for cellulitis has a history of alcohol use disorder and last drank 24 hours ago. The client is tremulous and anxious; vital signs: heart rate 108/min, blood pressure 154/88 mm Hg, respiratory rate 20/min, oxygen saturation 98% on room air; mental status: oriented; labs: magnesium 1.4 mg/dL (normal 1.7–2.2). Which intervention should the nurse implement IMMEDIATELY to reduce risk of complications?
Answer: Administer thiamine as prescribed before giving glucose-containing fluids or nutrition
This question tests nursing interventions and clinical judgment related to substance use, preventing complications in alcohol withdrawal. The priority concern is the client's tremors, anxiety, tachycardia, hypertension, and hypomagnesemia, with risk for Wernicke's encephalopathy. Administering thiamine before glucose is the best choice as it prevents neurological damage, supported by the vital signs and low magnesium. Ambulation increases fall risk; family history is not immediate; naloxone is for opioids. The underlying principle of care in substance use scenarios is nutritional supplementation to counter deficiencies from chronic alcohol use. Benzodiazepines address symptoms separately. A transferable nursing strategy is to routinely give thiamine, folate, and multivitamins in alcohol use disorder admissions.
- A 36-year-old client on a psychiatric unit has a history of methamphetamine use and has not slept for 2 days. The client is diaphoretic, has jaw clenching, and is yelling that staff are "trying to poison me"; vital signs: temperature 38.6°C (101.5°F), heart rate 140/min, blood pressure 174/110 mm Hg, respiratory rate 28/min; mental status: paranoid, escalating agitation; labs: potassium 4.0 mEq/L (normal 3.5–5.0). Which assessment finding requires IMMEDIATE attention?
Answer: Temperature 38.6°C (101.5°F) with severe agitation and tachycardia
This question tests nursing interventions and clinical judgment related to substance use, identifying critical signs in stimulant intoxication. The priority concern is the client's insomnia, diaphoresis, jaw clenching, paranoia, fever, tachycardia, and hypertension, signaling severe toxicity. The temperature of 38.6°C with agitation and tachycardia requires immediate attention as it indicates hyperthermia and risk for cardiac arrhythmia or rhabdomyolysis. Insomnia is expected; normal potassium is not urgent; paranoia is concerning but secondary to vital sign instability. The underlying principle of care in substance use scenarios is to address hyperadrenergic crises promptly to prevent organ damage. Cooling measures and benzodiazepines may be needed. A transferable nursing strategy is to monitor for dehydration and electrolyte shifts in prolonged stimulant use.
- A 46-year-old client is admitted for cellulitis and has a history of daily alcohol intake (10–12 drinks/day); last drink was 8 hours ago. The client is anxious with fine tremors and reports nausea; vital signs: temperature 37.0°C (98.6°F), heart rate 112/min, blood pressure 162/96 mm Hg, respiratory rate 20/min; mental status: alert and oriented; labs: aspartate aminotransferase (AST) 98 U/L (normal 10–40 U/L). Which intervention should the nurse implement IMMEDIATELY for this client?
Answer: Initiate a standardized alcohol-withdrawal assessment and administer prescribed medication based on the score
This question tests nursing interventions and clinical judgment related to substance use, specifically early alcohol withdrawal requiring systematic assessment and treatment. The priority concern is that this client with heavy daily alcohol use is showing early withdrawal signs (anxiety, tremors, nausea, elevated vital signs) 8 hours after last drink, requiring immediate standardized assessment to guide medication administration and prevent progression. Initiating standardized withdrawal assessment and administering medication based on scores (B) is the best choice because it provides objective measurement of withdrawal severity and ensures appropriate benzodiazepine dosing to prevent complications. Continuing routine vital signs (A) dangerously underestimates withdrawal risks, obtaining family history (C) delays urgent treatment, and methadone (D) is for opioid not alcohol withdrawal. The underlying principle is that alcohol withdrawal severity can progress rapidly, and standardized assessment tools (like CIWA-Ar) guide evidence-based treatment to prevent seizures and delirium tremens. The transferable nursing strategy is to use validated withdrawal assessment tools immediately upon recognizing early symptoms, reassess frequently, and administer medications based on objective scores rather than subjective judgment.
- A 57-year-old client is admitted for pneumonia and has a history of alcohol use disorder (6 beers nightly); last drink was 12 hours ago. The client has mild tremors, nausea, headache, and anxiety; vital signs: temperature 37.4°C (99.3°F), heart rate 104/min, blood pressure 154/92 mm Hg, respiratory rate 18/min; mental status: alert and oriented; labs: glucose 70 mg/dL (normal 70–110 mg/dL). What is the FIRST action the nurse should take for this client?
Answer: Administer prescribed thiamine before giving glucose-containing fluids or nutrition
This question tests nursing interventions and clinical judgment related to substance use, specifically early alcohol withdrawal with risk for Wernicke's encephalopathy. The priority concern is that this client with chronic alcohol use is at high risk for thiamine deficiency, and administering glucose without thiamine first can precipitate Wernicke's encephalopathy, a medical emergency causing confusion, ataxia, and eye movement abnormalities. Administering thiamine before glucose (A) is the best choice because it prevents this irreversible neurological complication while addressing the borderline low glucose safely. Disulfiram (B) is contraindicated during withdrawal, repeat alcohol levels (C) don't guide withdrawal treatment, and encouraging ambulation (D) could be unsafe with potential ataxia and doesn't address the thiamine deficiency. The underlying principle is that chronic alcohol use depletes thiamine stores, and glucose administration increases thiamine demand, potentially triggering Wernicke's encephalopathy if thiamine isn't replaced first. The transferable nursing strategy is to always administer thiamine before or with glucose in any patient with alcohol use disorder, regardless of withdrawal severity, to prevent permanent neurological damage.
- A 33-year-old client is brought to the emergency department for suspected opioid overdose; the client is unresponsive with respiratory rate 4/min, oxygen saturation 78% on room air, heart rate 48/min, blood pressure 86/50 mm Hg, and pinpoint pupils. After the nurse administers naloxone, the client becomes acutely agitated and reports severe body aches and diarrhea; vital signs: heart rate 118/min, blood pressure 156/92 mm Hg. Which intervention should the nurse implement IMMEDIATELY?
Answer: Maintain safety with verbal de-escalation, monitor airway and breathing, and prepare for repeat naloxone if respirations decline
This question tests nursing interventions and clinical judgment related to substance use, addressing precipitated opioid withdrawal after reversal. The priority concern is the client's acute agitation, body aches, diarrhea, tachycardia, and hypertension post-naloxone, with ongoing risk of respiratory depression recurrence. Maintaining safety with de-escalation and monitoring airway while preparing for repeat naloxone is the best choice as it balances withdrawal and overdose risks, per the vital signs shift. Restraints without de-escalation violate least-restrictive principles; urine screen delays care; benzodiazepine is not the reversal agent, a common error. The underlying principle of care in substance use scenarios is to anticipate withdrawal from antagonists and prioritize ABCs. Supportive care like hydration aids recovery. A transferable nursing strategy is to use team-based approaches for managing agitated clients in overdose situations.
