An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. What does the nurse suspect?
A schizophrenic episode
Hallucinogen ingestion
Opium intoxication
Cocaine overdose
The Correct Answer is B
A. A schizophrenic episode Schizophrenic episodes are characterized by a complex interplay of symptoms including delusions, hallucinations, disorganized thinking, and altered perceptions. While the client is experiencing altered perceptions, the sudden onset and specific description are more indicative of hallucinogen ingestion.
B. Hallucinogen ingestion The client's description of altered perception, feeling outside of their own body, and visual distortions are indicative of hallucinogen ingestion. This class of substances can cause profound alterations in perception, leading to hallucinations and distorted sensory experiences. The slightly elevated vital signs may be a physiological response to the effects of the hallucinogen.
C. Opium intoxication Opium is an opioid and its effects are characterized by sedation, respiratory depression, and miosis (pupil constriction). The client's description of altered perception and feeling outside of their body are not typical of opium intoxication.
D. Cocaine overdose Cocaine is a stimulant and its effects are characterized by increased heart rate, blood pressure, and hyperarousal. The client's description of altered perception and feeling outside of their body are not typical of cocaine overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect. Delusions of reference involve a belief that everyday events, objects, or other people have a particular and unusual significance. This is not described in the scenario.
B) Incorrect. Tangentiality is a thought disorder where the individual goes off on tangents and never returns to the original point or idea. This is not described in the scenario.
C) Incorrect. Neologism refers to the creation of new words or phrases that have meaning only to the person using them. This is not described in the scenario.
D) Correct. Loose associations are characterized by a disruption in the logical progression of thought, where thoughts become disorganized and may seem unrelated or loosely connected.
Correct Answer is D
Explanation
A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.
B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.
C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.
D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.
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