A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxyphenol-methamphetamine. Which of the following findings should the nurse expect?

Hallucinations

Muscle weakness

Hypothermia

Somnolence

Answer and Explanation

The Correct Answer is A

Explanation:

Methylenedioxyphenol-methamphetamine (MDMA), also known as ecstasy or Molly, is a psychoactive substance that can produce hallucinations as one of its effects. Hallucinations involve perceiving things that are not present in reality, such as seeing, hearing, or feeling things that do not actually exist.

Muscle weakness (choice B) is not a common finding associated with MDMA use. In fact, MDMA typically produces an increase in energy and heightened physical sensations rather than muscle weakness.

Hypothermia (choice C) can occur as a result of MDMA use. MDMA can interfere with the body's ability to regulate temperature, leading to an increase in body temperature. This is commonly known as "drug-induced hyperthermia" rather than hypothermia.

Somnolence (choice D), which refers to excessive sleepiness or drowsiness, is not typically associated with MDMA use. MDMA is a stimulant drug that can produce increased wakefulness and alertness.

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Correct Answer is D

Explanation

D. Maintain the client in high-Flower’s position

Crackles in the bases of the lungs, shortness of breath, and an increased respiratory rate are signs of pulmonary congestion, which is commonly seen in heart failure. Maintaining the client in a high-Fowler's position, with the head of the bed elevated to a 45-60-degree angle, helps reduce venous return to the heart, decreases fluid accumulation in the lungs, and improves breathing comfort for the client.

The other options are not appropriate actions for the client's condition:

Instructing the client to cough every 4 hours in (option A) is not the priority action in this situation. Coughing may not effectively address the underlying cause of pulmonary congestion and may not provide immediate relief for the client.

Encouraging the client to ambulate to loosen secretions in (option B) is not the priority action in this situation. While ambulation can be beneficial for overall health, the client's symptoms of pulmonary congestion require immediate attention to improve respiratory status.

Increasing the client's intake of oral fluids in (option C) is not the priority action in this situation. While maintaining adequate hydration is important, excessive fluid intake can worsen the symptoms of heart failure and contribute to further fluid accumulation in the lungs.

Therefore, the nurse should maintain the client in high-Fowler's position (option D) to promote optimal lung function and improve breathing comfort. It is important to promptly notify the healthcare provider of the client's condition for further assessment and intervention.

A. Dark red urine B. Frequent urge to urinate C. Urine output of 300 mL over 8 hr D. Occasional small clots in the urine

Correct Answer is A

Explanation

Dark red urine following a transurethral resection of the prostate (TURP) can indicate active bleeding or hematoma formation. It is important to notify the provider because further assessment and intervention may be necessary to address the source of the bleeding and prevent complications.

Frequent urge to urinate is expected after a TURP procedure as the bladder recovers and adapts to the changes. This is not a concerning finding and does not require immediate reporting to the provider.

Urine output of 300 mL over 8 hours can be considered adequate, especially in the early postoperative period. The nurse should continue to monitor the client's urinary output, but this finding does not require immediate reporting.

Occasional small clots in the urine can be expected after a TURP procedure due to the healing process and sloughing of tissue. However, if the clots become large or obstructive, or if there is a sudden increase in the frequency of clots, it should be reported to the provider.

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A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxyphenol-methamphetamine. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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