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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering diazepam may be part of the treatment plan for delirium tremens, but ensuring adequate hydration and addressing potential electrolyte imbalances is the first priority.
B. Raising the side rails is important for safety, but it is not the highest priority action at this time.
C. Obtaining a medical history is important for comprehensive care, but in this urgent situation, addressing fluid and electrolyte balance is the first priority.
D. Starting intravenous fluids is crucial for rehydration and addressing potential electrolyte imbalances, which is the priority in this emergency situation.
Correct Answer is B
Explanation
A) Incorrect. While kidney function is important for overall health, it is not the primary focus for ruling out medical conditions contributing to major depressive disorder.
B) Correct. Thyroid function can significantly impact mood and energy levels. Abnormalities in thyroid function can sometimes present with symptoms similar to depression, so a thyroid panel (including TSH, T3, and T4 levels) is an important test to consider.
C) Incorrect. While liver function is important for overall health, it is not the primary focus for ruling out medical conditions contributing to major depressive disorder.
D) Incorrect. A urinalysis with culture is not a standard test for ruling out medical conditions contributing to major depressive disorder. It is more relevant for assessing urinary tract infections or kidney function.
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