NCLEX-Style question

Question

A male patient is admitted with anxiousness, agitation, and a history of alcohol abuse. The nurse knows that the priority interaction is which of the following?

1. Administer Ativan (lorazepam) 1 mg IM now
2. Evaluate the patient's O₂ saturation and skin turgor
3. Teach the patient about slow breathing and its benefits
4. Gather data regarding the patient's last alcohol drink

Answer 1

With the symptoms and history placed in front of you with this question I do not think that it is an issue of oxygenation, rather one of acute alcohol withdrawal. Obtaining the pertinent information of the last drink can guide the interventions to prevent a seizure which could then compromise the airway.

1: ativan now may help, but IV lorazepam may be better suited for a faster onset

2: Nothing in this question says that the patients airway is compromised, skin turgor tests dehydration

3: an acutely anxious patient will not tolerate any teaching

4: last drink can give some insight as to how acute the potential withdrawal may be thus determine the appropriate intervention

Answer 2

Hi the question with the oxygen saturation and skin assessment is of priority, as although the patient has a history of anxiety, anxiety and skin changes can be a sign and symptom of cardiac, respiratory illness. This is an AIRWAY question. Thanks