An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. What does the nurse suspect?

A schizophrenic episode

Hallucinogen ingestion

Opium intoxication

Cocaine overdose

Answer and Explanation

The Correct Answer is B

A. A schizophrenic episode Schizophrenic episodes are characterized by a complex interplay of symptoms including delusions, hallucinations, disorganized thinking, and altered perceptions. While the client is experiencing altered perceptions, the sudden onset and specific description are more indicative of hallucinogen ingestion.

B. Hallucinogen ingestion The client's description of altered perception, feeling outside of their own body, and visual distortions are indicative of hallucinogen ingestion. This class of substances can cause profound alterations in perception, leading to hallucinations and distorted sensory experiences. The slightly elevated vital signs may be a physiological response to the effects of the hallucinogen.

C. Opium intoxication Opium is an opioid and its effects are characterized by sedation, respiratory depression, and miosis (pupil constriction). The client's description of altered perception and feeling outside of their body are not typical of opium intoxication.

D. Cocaine overdose Cocaine is a stimulant and its effects are characterized by increased heart rate, blood pressure, and hyperarousal. The client's description of altered perception and feeling outside of their body are not typical of cocaine overdose.

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Correct Answer is A

Explanation

A. Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B. A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C. A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D. Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.

A. "Why do you want to kill yourself?" B. "Do you have access to medications?" C. "Have you been taking drugs and alcohol?" D. "Did something happen with your parents?"

Correct Answer is B

Explanation

A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.

B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.

C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.

D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.

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An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. What does the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

Correct Answer is A

Explanation

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

Correct Answer is B

Explanation

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?

The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?

What client population is at risk of developing tardive dyskinesia?

A nurse is caring for a client diagnosed with schizophrenia following a recent suicide attempt. Which of the following actions should the nurse take?

A client is admitted to the emergency department after using ecstasy. The nurse identifies this drug as belonging to what class?

A client is showing early signs of dementia. The client's spouse asks, "What may I expect next?" What is the nurse's best response?