The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Bradycardia and bradypnea.

Stimulation and dilated pupils.

Hallucinations and delusions.

Lethargy and depression.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Cocaine is a stimulant and typically leads to increased heart rate (tachycardia) and respiratory rate (tachypnea). Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) would be atypical findings with cocaine use.

Choice B rationale:
Cocaine is a stimulant drug that typically produces effects such as increased heart rate, increased blood pressure, stimulation, euphoria, and dilated pupils. These physiological and psychological effects are common when someone has used cocaine.

Choice C rationale:
While cocaine use can cause hallucinations and paranoia during intoxication or withdrawal, these symptoms are not typically the primary manifestations. The most common initial effects are stimulation and increased alertness.
Hallucinations and delusions may occur with substance use, but they are not the most expected or specific findings for cocaine use.

Choice D rationale:
Cocaine use is associated with increased energy, euphoria, and heightened arousal. Lethargy and depression are more likely during the comedown phase or withdrawal from cocaine, rather than immediately after use.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Assisting the client with relaxation techniques within the group may be ineffective for severe anxiety because the client may be too overwhelmed by the environment to participate or focus.

B. Escorting the client from the group to a quieter environment is the most effective intervention for severe anxiety. Reducing external stimuli allows the client to regain composure and prevents escalation of physiological and psychological stress responses.

C. Providing education about coping strategies is appropriate for mild or moderate anxiety, but during severe anxiety the client is unlikely to process or retain information effectively.

D. Asking the client to describe or identify the source of feelings can increase anxiety and is not therapeutic during a severe anxiety episode. Exploration of triggers is more appropriate once the client is calmer.

A. Call and give a report immediately B. Administer loop diuretic C. Schedule for Hemodialysis immediately D. Check blood glucose level E. Draw a repeat potassium level F. Hold Lisinopril G. Administer insulin, dextrose 50%, and calcium gluconate. Then repeat 12 lead EKG

Correct Answer is ["C","D","E","F","G"]

Explanation

Choice A rationale:
This is not a priority action for the nurse at this time. The nurse should first implement the ordered treatments for hyperkalemia and stabilize the client's condition before calling and giving a report to the receiving unit.

Choice B rationale:
Loop diuretics are medications that increase urine output and can lower potassium levels in mild cases of hyperkalemia. However, they are contraindicated in patients with ERSD who have oliguria or anuria (reduced or absent urine production). Loop diuretics can worsen renal function and fluid overload in these patients.

Choice C rationale:
Scheduling the client for hemodialysis is crucial, especially if the client has missed a scheduled dialysis session. Hemodialysis can help manage electrolyte imbalances and fluid overload.

Choice D rationale:
Checking the blood glucose level is important, especially in a client with a history of diabetes. Maintaining glycemic control is essential for overall health.

Choice E rationale:
Drawing a repeat potassium level is necessary to monitor the client's electrolyte status, especially given the ECG changes.

Choice F rationale:
Holding Lisinopril, an ACE inhibitor, is appropriate in this context, considering the client's elevated blood pressure and potential renal issues. It should be done under the guidance of the healthcare provider.

Choice G rationale:
Administering insulin, dextrose, and calcium gluconate can help manage hyperkalemia, which may be indicated by the ECG changes. Repeating the 12-lead EKG is important to assess the response to treatment and any changes in cardiac rhythm.

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The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is ["C","D","E","F","G"]

Explanation

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