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Sedated, heightened senses, withdrawn.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.
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Sedated, heightened senses, withdrawn.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Is not responding to other clients on the unit.
While a lack of response to other clients can indicate social withdrawal and isolation, which are common in depressive episodes, it does not necessarily indicate an immediate risk to the client’s safety. This behavior is concerning but does not require the highest priority intervention compared to other behaviors that may indicate a risk of self-harm or suicidal ideation.
Choice B Reason: Is refusing to take their prescribed mood stabilizer.
Refusing medication is a significant concern as it can lead to worsening of symptoms and destabilization of the client’s condition. However, this behavior does not indicate an immediate risk to the client’s safety. The nurse should address this issue promptly, but it is not the highest priority compared to behaviors that suggest suicidal ideation.
Choice C Reason: Angrily argues with another client stating, “God is dead.”
This behavior indicates agitation and potential conflict with others, which can be problematic in a clinical setting. However, it does not directly suggest an immediate risk to the client’s safety. The nurse should intervene to de-escalate the situation and provide support, but this is not the highest priority compared to signs of suicidal ideation.
Choice D Reason: States, “There is no future when you feel so depressed.”
This statement is highly concerning as it indicates feelings of hopelessness and potential suicidal ideation. Expressions of hopelessness and statements about the future being bleak are significant risk factors for suicide. The nurse should prioritize this behavior for immediate intervention to assess the client’s risk of self-harm and provide appropriate support and safety measures.
Correct Answer is C
Explanation
Choice A Reason: We can call Alcoholics Anonymous (AA) and go to a closed meeting to see what happens inside.
Alcoholics Anonymous (AA) is a support group specifically for individuals struggling with alcohol use disorder. Closed meetings are typically reserved for those who identify as alcoholics and are seeking help for their own drinking problems. Family members and friends are generally not allowed to attend these meetings unless they are open meetings. Therefore, this choice does not reflect an effective understanding of the appropriate support resources available for family members.
Choice B Reason: We should wait until the client is ready to stop drinking before the family goes to support meetings.
Waiting until the client is ready to stop drinking before seeking support is not advisable. Family members can benefit from attending support groups like Al-Anon regardless of the client’s readiness to change. These groups provide emotional support, education, and coping strategies for dealing with the challenges of living with someone who has an alcohol use disorder. This choice suggests a misunderstanding of the importance of seeking support for oneself, independent of the client’s actions.
Choice C Reason: The family can go to Al-Anon meetings for support.
Al-Anon is a support group specifically designed for family members and friends of individuals with alcohol use disorder. These meetings provide a safe space for loved ones to share their experiences, gain support, and learn effective coping strategies. Attending Al-Anon meetings can help family members understand the nature of addiction, reduce feelings of isolation, and improve their own well-being. This choice reflects an accurate understanding of the appropriate support resources available for families.
Choice D Reason: Support groups are an option for the client, not the family.
This statement is incorrect because support groups like Al-Anon are specifically designed for family members and friends of individuals with alcohol use disorder. These groups recognize that addiction affects not only the individual but also their loved ones. By participating in support groups, family members can gain valuable insights, emotional support, and practical advice for coping with the challenges associated with a loved one’s addiction. This choice reflects a misunderstanding of the role and availability of support groups for families.
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