Question

In the ED, a patient's vitals are BP 66/40, pulse 140, respiration 8 breaths and shallow. The nursing diagnosis is ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority.

1) The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization
2) Within 4 hours, vital signs will stabilize, with BP 90/60 pulse less than 100, and respiration at or above 12
3) The patient will correctly describe a plan for home care and achieving a drug-free state before release from the ED
4) Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields

Answer 1

The priority for a patient with an ineffective breathing pattern and severely unstable vital signs is to stabilize those signs, specifically targeting a blood pressure of 90/60, pulse rate under 100, and a respiration rate at or above 12 within 4 hours. so, option 2 is the correct answer.

Step-by-step explanation:

The question concerns a patient with vital signs that are indicative of severe instability and potentially life-threatening condition. In particular, the nursing diagnosis is centered on ineffective breathing pattern related to respiratory depression due to narcotic intoxication. Among the options provided, the priority should be to stabilize the patient's vital signs as they take precedence over long-term goals like coping skills and discharge planning at this critical juncture. Therefore, the correct answer is:

Within 4 hours, vital signs will stabilize, with BP 90/60 pulse less than 100, and respiration at or above 12

This is because immediate physiological stability is essential for ensuring survival and is a prerequisite for any subsequent care or recovery plans.

The priority nursing diagnosis for the patient with vitals of BP 66/40, pulse 140, respiration 8 breaths, and shallow is 2) Within 4 hours, vital signs will stabilize with BP 90/60, pulse less than 100, and respiration at or above 12.

The given vitals indicate a critical condition and immediate intervention is required to stabilize the patient. Low blood pressure, tachycardia (fast heart rate), and shallow breathing suggest inadequate oxygen supply to the body. The priority should be to address the ineffective breathing pattern and aim to stabilize the vital signs within 4 hours.