Page 2314 - Saunders Comprehensive Review For NCLEX-RN

Intoxication: Inhalants

▪ Enhancement of sexual pleasure
▪ Euphoria
▪ Excitation followed by drowsiness, lightheadedness, disinhibition, and agitation
▪ Giggling and laughter

Box 66-11

Withdrawal: Nursing Care

▪ Obtain information regarding the type of drug and amount consumed.
▪ Assess vital signs.
▪ Remove unnecessary objects from the environment.
▪ Provide one-to-one supervision if necessary.

▪ Provide a quiet, calm environment with minimal stimuli.
▪ Maintain client orientation.
▪ Ensure the client’s safety by implementing seizure precautions.
▪ Use security devices if necessary and as prescribed to prevent the client from
harming self and others.
▪ Provide for physical needs.
▪ Provide food and fluids as tolerated.
▪ Administer medications as prescribed to decrease withdrawal symptoms.
▪ Collect blood and urine samples for drug screening.

Practice Questions

817. The home health nurse visits a client at home and determines that the client
is dependent on drugs. During the assessment, which action should the
nurse take to plan appropriate nursing care?
1. Ask the client why he started taking illegal drugs.
2. Ask the client about the amount of drug use and its effect.
3. Ask the client how long he thought that he could take drugs
without someone finding out.
4. Do not ask any questions for fear that the client is in denial and
will throw the nurse out of the home.
818. Which interventions are most appropriate for caring for a client in alcohol
withdrawal? Select all that apply.

1. Monitor vital signs.

2. Provide a safe environment.

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