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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Range-of-motion exercises are within the scope of practice for an AP and do not require specialized nursing knowledge or assessment skills. The AP can assist the client in performing these exercises to promote circulation, maintain joint mobility, and prevent complications associated with immobilization.

Determining the circulation status of the affected extremities, evaluating the need for restraints, and providing education to the client's family about the purpose of restraints require nursing assessment, critical thinking, and communication skills. These tasks should be performed by a licensed nurse who can make clinical judgments and ensure the safety and well-being of the client.

A. Apply a warm compress. B. Document the infiltration. C. Stop the infusion. D. Elevate the arm.

Correct Answer is C

Explanation

The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.

Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.

Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.

Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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