A nurse is assisting in the admission of a 30-year-old client to an inpatient mental health facility.

Exhibits

For each finding, click to specify if the finding is consistent with opioid, stimulant, or hallucinogen intoxication. Each finding may be consistent with more than 1 substance or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Seizures

Tachycardia

Sedation

Dilated pupils

Paranoia

Pinpoint pupils

Hypertension

Answer and Explanation

The Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B,C"},"C":{"answers":"A"},"D":{"answers":"B,C"},"E":{"answers":"B,C"},"F":{"answers":"A"},"G":{"answers":"B,C"}}

Rationales for Each Condition

Opioid Intoxication

Sedation: Opioids cause central nervous system depression, leading to drowsiness, confusion, and reduced level of consciousness.
Pinpoint Pupils: A hallmark sign of opioid intoxication is miosis (pinpoint pupils) due to parasympathetic nervous system activation.

Stimulant Intoxication (e.g., Methamphetamine)

Seizures: Stimulants can lower the seizure threshold, increasing the risk of convulsions.
Tachycardia: Stimulants induce sympathetic activation, leading to increased heart rate.
Dilated Pupils: Sympathetic nervous system stimulation causes pupil dilation (mydriasis).
Paranoia: Stimulant intoxication often results in psychosis, including paranoia and hallucinations.
Hypertension: Elevated catecholamines increase blood pressure, seen in stimulant intoxication.

Hallucinogen Intoxication

Seizures: Some hallucinogens (e.g., LSD) can induce seizures due to excitatory effects.
Tachycardia: Hallucinogens stimulate the autonomic nervous system, increasing heart rate.
Dilated Pupils: Similar to stimulants, hallucinogens can cause mydriasis.
Paranoia: Hallucinogen intoxication can result in psychosis, including paranoia.
Hypertension: Increased autonomic activity leads to elevated blood pressure.

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Free Nursing Study Resources

Correct Answer is ["15"]

Explanation

Step 1 is: Determine the desired dose: 7.5 mg.

Step 2 is: Determine the concentration on hand: 2.5 mg ÷ 5 mL.

Step 3 is: Set up the calculation: (7.5 mg × 5 mL) ÷ 2.5 mg.

Step 4 is: Perform the multiplication: 37.5 mg·mL ÷ 2.5 mg.

Step 5 is: Perform the division: 15 mL.

Final answer: The nurse should administer 15 mL.

A. Keep the client's room dark at night. B. Limit the client's need to make decisions. C. Discourage visitation from the client's family. D. Provide a consistent daily routine.

Correct Answer is D

Explanation

Choice A rationale

Keeping the client's room dark at night can worsen delirium by reducing environmental cues and potentially increasing disorientation and fear. Clients with delirium benefit from a well-lit environment that helps them maintain a sense of reality and reduces the risk of misinterpreting stimuli.

Choice B rationale

Limiting the client's need to make decisions can decrease their sense of control and autonomy, potentially increasing agitation and frustration associated with delirium. While simplifying choices is helpful, completely eliminating decision-making can be counterproductive to their engagement and orientation.

Choice C rationale

Discouraging visitation from the client's family can increase the client's feelings of isolation and anxiety, which can exacerbate delirium. Familiar faces and voices can provide comfort and reassurance, aiding in orientation and reducing agitation.

Choice D rationale

Providing a consistent daily routine helps to orient the client with acute delirium to time and place, reducing confusion and anxiety. Predictable patterns of activity, such as meals, hygiene, and rest, offer structure and familiarity, which can stabilize cognitive function and promote a sense of security.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer fluphenazine 7.5 mg PO daily to a client who has schizophrenia. Available is fluphenazine elixir 2.5 mg/5 mL. How many mL should the nurse administer?

Correct Answer is ["15"]

Explanation

A nurse is contributing to the plan of care for a client who has acute delirium.Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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