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 A
Explanation
A. This outcome is specific, measurable, and timebound. It addresses the client's impaired social interactions and sets a realistic expectation for improvement within a short timeframe.
B. While this outcome is specific, it may not be achievable within a short timeframe and may not directly address the issue of egocentrism.
C. This outcome focuses on verbalization but may not necessarily lead to actual interaction or address the issue of egocentrism.
D. While this outcome is relevant, it is not as specific or timebound as option A.
Correct Answer is A
Explanation
A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This
intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.
B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.
C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.
D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.
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