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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

A. Have the client go to his room until calm. B. Politely ask the client to stop talking. C. Speak slowly and in a quiet voice to help the client focus. D. Encourage the client to talk more so you can determine what he is thinking.

Correct Answer is C

Explanation

A) Incorrect. Isolating the client in his room may escalate the situation or make the client feel isolated and misunderstood.

B) Incorrect. Asking the client to stop talking may be perceived as confrontational and could potentially agitate the client further.

C) Correct. Speaking slowly and in a quiet voice can help the client focus and may reduce the flight of ideas. This calm approach can be grounding for the client.

D) Incorrect. Encouraging the client to talk more may exacerbate the flight of ideas and the manic state.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is C

Explanation

A client diagnosed with bipolar I disorder is in a manic state, rushing about the unit, and talking regularly with a flight of ideas. What is the most therapeutic intervention?

Correct Answer is C

Explanation

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