A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxyphenol-methamphetamine. Which of the following findings should the nurse expect?
Hallucinations
Muscle weakness
Hypothermia
Somnolence
The Correct Answer is A
Explanation:
Methylenedioxyphenol-methamphetamine (MDMA), also known as ecstasy or Molly, is a psychoactive substance that can produce hallucinations as one of its effects. Hallucinations involve perceiving things that are not present in reality, such as seeing, hearing, or feeling things that do not actually exist.
Muscle weakness (choice B) is not a common finding associated with MDMA use. In fact, MDMA typically produces an increase in energy and heightened physical sensations rather than muscle weakness.
Hypothermia (choice C) can occur as a result of MDMA use. MDMA can interfere with the body's ability to regulate temperature, leading to an increase in body temperature. This is commonly known as "drug-induced hyperthermia" rather than hypothermia.
Somnolence (choice D), which refers to excessive sleepiness or drowsiness, is not typically associated with MDMA use. MDMA is a stimulant drug that can produce increased wakefulness and alertness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.
The other options are not appropriate based on the information provided:
- "Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
- "Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
- "Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
- "Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.
Correct Answer is B
Explanation
This step is part of the process when mixing NPH and regular insulin in a single syringe. After injecting air into the NPH insulin vial, you should inject an equal amount of air (in this case, 15 units) into the regular insulin vial to maintain pressure balance. This allows for easy withdrawal of the prescribed doses of each insulin type in the same syringe without causing a vacuum in the vials.
After injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.
Verifying the dosage with another nurse is not necessary in this step, as it is done prior to drawing up the insulin. However, it is good practice to have another nurse double-check the dosage before administration.
Injecting air into the regular insulin vial is not required at this stage. It is only necessary when withdrawing the regular insulin dose.
Placing the cap over the needle should be done after withdrawing the desired dose of insulin and before administering it to the client for safety and to prevent needlestick injuries.
The correct sequence when mixing NPH and regular insulin in a single syringe is as follows:
- Inject air into the NPH insulin vial (in this case, 10 units of air).
- Inject air into the regular insulin vial (in this case, 15 units of air).
- Withdraw the prescribed dose of NPH insulin (10 units) from the NPH vial.
- Withdraw the prescribed dose of regular insulin (15 units) from the regular insulin vial.
So, after injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.
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