A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me." The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
Opium
Heroin
Alcohol
Cocaine
The Correct Answer is D
Cocaine is a stimulant that can cause paranoia, increased heart rate, and elevated blood pressure in high doses or during acute intoxication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The priority for the nurse is to ensure safety for the client and others in the facility. Asking the client about his or her intentions can help the nurse determine the level of risk and plan appropriate interventions, such as setting limits, providing supervision, or initiating seclusion or restraint if necessary.
Correct Answer is B
Explanation
A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.
B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.
C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.
D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.