A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for alcohol intoxication. The nurse enters the room and finds the client shouting "Get those bugs off of me." Which of the following responses should the nurse make?
"I'm sure that the bugs you see will not harm you."
"I don't see any bugs, but you seem very frightened."
"Let's get out of your room so that the bugs will not bother you
“There are no bugs in here. This is part of your illness."
The Correct Answer is B
A. "I'm sure that the bugs you see will not harm you.": This response validates the hallucination and may increase the client's anxiety.
B. "I don't see any bugs, but you seem very frightened.": This response maintains reality orientation while acknowledging the client’s emotional state, a therapeutic and non-confrontational approach.
C. "Let's get out of your room so that the bugs will not bother you": This reinforces the hallucination and may worsen disorientation.
D. “There are no bugs in here. This is part of your illness.": This is too blunt and dismissive, potentially increasing defensiveness or agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 0.10%
This was the legal limit in the past, but not currently in most states.
B. 0.5%
A level of 0.5% would likely result in coma or death.
C. 0.08%
This is the current legal limit in most U.S. states for blood alcohol concentration (BAC) when operating a motor vehicle.
D. 0.12%
Higher than the legal limit. A person with this BAC would be considered legally impaired.
Correct Answer is B
Explanation
A. clear, constricted pupils
Cocaine is a stimulant and causes dilated (not constricted) pupils during intoxication. Constricted pupils are more characteristic of opioid use.
B. red, irritated nostrils
Snorting cocaine repeatedly causes irritation to nasal passages, leading to redness, inflammation, and even nosebleeds or septal perforation.
C. conjunctival redness
This is more commonly seen with marijuana use, not cocaine.
D. muscle aches
Not a hallmark symptom of long-term cocaine use.
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