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 C
Explanation
A. While providing reassurance is important, this response does not directly address the client's statement about future attempts.
B. This response may minimize the seriousness of the client's statement and is not the best way to address the situation.
C. This response directly addresses the client's statement, seeking clarification on her plans. It is important to assess the level of risk and ensure the client's safety.
D. While expressing empathy and highlighting the client's positive qualities can be helpful, it may not directly address the immediate concern of the client's statement about future attempts.
Correct Answer is C
Explanation
A. While understanding precipitating factors is important, it is not the immediate priority when the client is actively experiencing hallucinations.
B. Distracting the client may not address the underlying cause of the hallucinations, which should be the priority.
C. Determining the content of the hallucinations can provide important information for assessment and intervention.
D. Dismissing the client's experience can be alienating and unhelpful.
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