A nurse is collecting data from a client who reports recently using cocaine. Which of the following manifestations should the nurse expect?

Hyperthermia

Increased appetite

Sedation

Hypotension

Answer and Explanation

The Correct Answer is A

A. Hyperthermia: Cocaine is a stimulant that increases sympathetic nervous system activity, leading to elevated body temperature, tachycardia, and hypertension. Hyperthermia is a common acute effect of cocaine use.

B. Increased appetite: Cocaine typically suppresses appetite due to its stimulant effects on the central nervous system. Clients often experience decreased hunger rather than increased appetite.

C. Sedation: Cocaine use generally causes CNS stimulation, resulting in agitation, restlessness, or insomnia rather than sedation. Sedative effects are more characteristic of depressant substances.

D. Hypotension: Cocaine causes vasoconstriction and sympathetic stimulation, which usually leads to elevated blood pressure. Hypotension is not expected and may indicate a complication or co-ingestion of another substance.

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Correct Answer is A

Explanation

A. “Are you thinking of hurting yourself?”: This response directly and calmly assesses for suicidal ideation, which is essential when a client expresses feelings of worthlessness or passive death wishes. Asking clearly about self-harm allows the nurse to determine risk and initiate appropriate safety interventions.

B. “What would your family do without you?”: This response may increase guilt or emotional distress rather than encouraging open communication. It does not assess the client’s immediate safety or suicidal thoughts.

C. “When you get better you will not feel this way.”: This response minimizes the client’s current feelings and may make the client feel unheard or dismissed. It does not address potential suicidal risk or provide emotional support.

D. “Why would you think a thing like that?”: Asking “why” can sound judgmental and may discourage the client from sharing further. It does not assess for suicidal intent and may increase defensiveness or withdrawal.

A. Heart rate B. Pedal pulses C. Breath sounds D. Abdominal dressing E. Respiratory rate F. Oxygen saturation

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

Explanation

A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.

B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.

C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.

D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.

E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.

F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.

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A nurse is collecting data from a client who reports recently using cocaine. Which of the following manifestations should the nurse expect?

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