A nurse is assisting in the admission of a 30-year-old client to an inpatient mental health facility.
For each finding, click to specify if the finding is consistent with opioid, stimulant, or hallucinogen intoxication. Each finding may be consistent with more than 1 substance or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
Seizures
Tachycardia
Sedation
Dilated pupils
Paranoia
Pinpoint pupils
Hypertension
The Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B,C"},"C":{"answers":"A"},"D":{"answers":"B,C"},"E":{"answers":"B,C"},"F":{"answers":"A"},"G":{"answers":"B,C"}}
Rationales for Each Condition
Opioid Intoxication
- Sedation: Opioids cause central nervous system depression, leading to drowsiness, confusion, and reduced level of consciousness.
- Pinpoint Pupils: A hallmark sign of opioid intoxication is miosis (pinpoint pupils) due to parasympathetic nervous system activation.
Stimulant Intoxication (e.g., Methamphetamine)
- Seizures: Stimulants can lower the seizure threshold, increasing the risk of convulsions.
- Tachycardia: Stimulants induce sympathetic activation, leading to increased heart rate.
- Dilated Pupils: Sympathetic nervous system stimulation causes pupil dilation (mydriasis).
- Paranoia: Stimulant intoxication often results in psychosis, including paranoia and hallucinations.
- Hypertension: Elevated catecholamines increase blood pressure, seen in stimulant intoxication.
Hallucinogen Intoxication
- Seizures: Some hallucinogens (e.g., LSD) can induce seizures due to excitatory effects.
- Tachycardia: Hallucinogens stimulate the autonomic nervous system, increasing heart rate.
- Dilated Pupils: Similar to stimulants, hallucinogens can cause mydriasis.
- Paranoia: Hallucinogen intoxication can result in psychosis, including paranoia.
- Hypertension: Increased autonomic activity leads to elevated blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
"If the provider prescribes medication, I will have to administer it" is an inaccurate statement regarding a voluntarily admitted client's rights. Voluntarily admitted clients generally retain the right to refuse medication, even if it is prescribed by a provider. This response undermines the client's autonomy.
Choice B rationale
"You agreed to take medication when you decided to be admitted" is also generally inaccurate for voluntary admissions. While the client may agree to a treatment plan that includes medication, voluntary admission itself does not automatically equate to mandatory medication administration. The client still has the right to refuse.
Choice C rationale
"You have the right to refuse to take the medication" is the correct and most appropriate response. Voluntarily admitted clients retain their right to informed consent and the right to refuse treatment, including medication, unless there is a specific court order indicating otherwise or an imminent risk of harm to themselves or others. This response respects the client's autonomy.
Choice D rationale
"I can make a list of the medications that you don't want to take" is a helpful action in acknowledging the client's concern and preferences. However, it does not directly address the client's question about their right to refuse medication. While documenting preferences is important, the initial response should clearly state their right to refusal. .
Correct Answer is C
Explanation
Choice A rationale
Assisting the client with evaluating their coping mechanisms is a helpful strategy for preventing future panic attacks and managing anxiety in the long term. However, during an acute panic attack, the client's ability to think rationally and evaluate their coping skills is significantly impaired. The immediate focus should be on reducing overwhelming stimuli.
Choice B rationale
Exploring with the client what precipitates an attack is crucial for identifying triggers and developing preventative strategies. However, during an active panic attack, the client is experiencing intense anxiety and may not be able to effectively process or articulate potential triggers. This intervention is more appropriate for periods between attacks.
Choice C rationale
Minimizing environmental stimuli is a key intervention during a panic attack. Panic attacks involve a surge of intense fear and anxiety, often accompanied by sensory overload. Reducing noise, bright lights, and excessive activity in the immediate surroundings can help decrease the client's distress and promote a sense of calm and safety.
Choice D rationale
Encouraging the client to set goals is a therapeutic strategy aimed at promoting a sense of control and accomplishment, which can be beneficial for overall mental health and managing anxiety in the long term. However, during an acute panic attack, the client is likely overwhelmed and unable to focus on goal setting. The immediate priority is to reduce their acute anxiety.
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