A nurse is assessing a client who is experiencing acute cocaine toxicity. Which of the following findings should the nurse expect?
Hypothermia
Hypotension
Tremors
Respiratory depression
The Correct Answer is C
Tremors: This choice is correct. Tremors or muscle twitching can be expected in a client experiencing acute cocaine toxicity. Cocaine is a central nervous system stimulant that can cause overstimulation of muscles, resulting in tremors.
Incorrect:
A- Hypothermia: This choice is incorrect. Acute cocaine toxicity is associated with an increase in body temperature (hyperthermia) rather than a decrease (hypothermia). Cocaine is a stimulant that can cause the body to overheat, leading to hyperthermia, which is a dangerous condition that requires immediate medical attention.
B- Hypotension: This choice is incorrect. Cocaine is a stimulant that increases blood pressure and heart rate, leading to hypertension (high blood pressure), not hypotension (low blood pressure). Hypertension is a common cardiovascular effect of cocaine use.
D- Respiratory depression: This choice is incorrect. Respiratory depression, which is a slowing of the respiratory rate and depth, is more commonly associated with depressant drugs like opioids or benzodiazepines. As a stimulant, cocaine tends to have the opposite effect, leading to increased respiratory rate (tachypnea) and sometimes hyperventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.
A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.
B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.
C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.
Correct Answer is D
Explanation
This response acknowledges the client's feelings and respects their desire for space and silence. By offering to sit with the client, the nurse provides a comforting presence without pressuring the client to talk or share their emotions. It shows understanding and support for the client's current emotional state.
The other options may not be as helpful in this situation:
A- "Why are you feeling so down?" can be seen as intrusive and may make the client feel defensive or overwhelmed. It's important to respect the client's boundaries and not push them to explain their feelings if they are not ready.
B- "It might help you feel better if you talk about it." While talking about feelings can be beneficial for some individuals, it should be done on the client's terms. Pressuring the client to talk about their emotions may create additional distress.
C- "I understand. I've felt like that before, too." While sharing personal experiences can be a way to establish rapport, it should be done cautiously and with consideration for the client's unique situation. In this case, the focus should be on the client's needs rather than the nurse's experiences.
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