Management of Care Q 9
A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A. A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”
B. A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?”
C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11,
D. An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room.
Correct Answer: C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10.
Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. This client exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.
Option A: The client in option A might be experiencing an overdose.
Option B: The client in option B is having withdrawal syndrome.
Option D: The client in option D may experience a decrease in sensorium later on due to head trauma.