A client presents to the Emergency Department (ED) after ingesting phencyclidine (PCP). Characteristic behaviors of an individual who has ingested PCP include:

Sedated, heightened senses, withdrawn.

Heightened sensory perceptions, nystagmus, hypotension.

Grandiose delusions, hypotension, quiet.

Violence, psychomotor agitation, hypertension.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Sedated, heightened senses, withdrawn. This statement is incorrect. While PCP can cause a range of sensory and psychological effects, sedation and withdrawal are not typical primary symptoms. PCP is more likely to cause agitation and aggressive behavior rather than sedation.

Choice B Reason:

Heightened sensory perceptions, nystagmus, hypotension. This statement is partially correct. PCP can cause heightened sensory perceptions and nystagmus (rapid, involuntary eye movements), but hypotension is not a common symptom. Instead, PCP often leads to hypertension (high blood pressure) due to its stimulant effects.

Choice C Reason:

Grandiose delusions, hypotension, quiet. This statement is incorrect. While PCP can cause grandiose delusions, it is more likely to result in agitation and aggressive behavior rather than a quiet demeanor. Hypotension is also not a typical symptom of PCP intoxication.

Choice D Reason:

Violence, psychomotor agitation, hypertension. This statement is correct. PCP intoxication is commonly associated with violent behavior, psychomotor agitation, and hypertension. These symptoms are due to the drug’s stimulant and dissociative effects, which can lead to severe agitation and aggressive behavior.

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Correct Answer is ["125"]

Explanation

Calculation Steps

Step 1: Convert 1 liter to milliliters (mL).

1 liter = 1000 mL

Result: 1000 mL

Step 2: Determine the total time in hours.

Total time = 8 hours

Result: 8 hours

Step 3: Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate = Total volume (mL) ÷ Total time (hours)

Step 4: Perform the division.

1000 mL ÷ 8 hours = 125 mL/hr

Result: 125 mL/hr

Therefore, the nurse should set the infusion pump to 125 mL/hr.

A. Distinct wound borders to plantar aspect of foot B. +3 edema to the mid-calf C. Patient reports 9 (0-10) pain scale to area D. Irregular wound borders E. Minimal serous drainage

Correct Answer is ["B","D","E"]

Explanation

b. +3 edema to the mid-calf

d. Irregular wound borders

e. Minimal serous drainage

Explanation of Choices

Choice A Reason: Distinct Wound Borders to Plantar Aspect of Foot

Venous ulcers typically present with irregular wound borders rather than distinct ones. They are usually found on the lower legs, particularly around the medial malleolus (inner ankle), rather than the plantar aspect of the foot. The plantar aspect of the foot is more commonly associated with diabetic ulcers or pressure sores. Therefore, distinct wound borders to the plantar aspect of the foot are not indicative of a venous ulcer.

Choice B Reason: +3 Edema to the Mid-Calf

Edema, or swelling, is a common finding in patients with venous ulcers. Venous insufficiency leads to increased pressure in the veins, causing fluid to leak into the surrounding tissues, resulting in edema. The presence of +3 edema (a significant level of swelling) in the mid-calf is a strong indicator of venous insufficiency and, consequently, venous ulcers. This finding supports the diagnosis of a venous ulcer.

Choice C Reason: Patient Reports 9 (0-10) Pain Scale to Area

While pain can be associated with venous ulcers, it is not a definitive diagnostic criterion. Pain levels can vary widely among individuals with venous ulcers, and some may experience minimal discomfort. A pain scale rating of 9 out of 10 indicates severe pain, which could be due to various conditions, not specifically venous ulcers. Therefore, this finding alone is not sufficient to suspect a venous ulcer.

Choice D Reason: Irregular Wound Borders

Venous ulcers are characterized by their irregular wound borders. Unlike arterial ulcers, which have well-defined edges, venous ulcers tend to have uneven, irregular borders. This is due to the chronic nature of venous insufficiency and the ongoing damage to the skin and underlying tissues. The presence of irregular wound borders is a key indicator of a venous ulcer.

Choice E Reason: Minimal Serous Drainage

Venous ulcers often produce serous drainage, which is a clear to pale yellow fluid. The amount of drainage can vary, but minimal serous drainage is a common finding. This type of drainage is due to the chronic inflammation and fluid leakage associated with venous insufficiency. Therefore, minimal serous drainage is consistent with the presence of a venous ulcer.

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A client presents to the Emergency Department (ED) after ingesting phencyclidine (PCP). Characteristic behaviors of an individual who has ingested PCP include:

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Naxlex Comprehensive Predictor Exams

One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

Correct Answer is ["125"]

Explanation

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

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