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 ["B","C","D"]

Explanation

A) Incorrect. While it's important to avoid dehydration, this option is not specific to lithium use.

B) Correct. Lithium can cause dehydration, so it's crucial for the client to drink adequate fluids daily.

C) Correct. A low sodium diet is important while taking lithium, as high sodium levels can affect lithium absorption and potentially lead to toxicity.

D) Correct. Routine blood work is necessary to monitor lithium levels and ensure the client's levels remain within the therapeutic range.

E) Incorrect. Dependency is not a common concern with lithium.

A. Establish a healthy sleeping, eating, and exercise routine. B. Prevent overscheduling and becoming fatigued and exhausted. Reach out to reconnect with old buddies to test strength in resistance. C. Have a friend or counselor number to call when having doubts. D. Schedule plenty of quiet, unstructured alone time, for television Attend outpatient and community support groups for addiction.

Correct Answer is ["A","C","D"]

Explanation

A. Establish a healthy sleeping, eating, and exercise routine This is an important relapse prevention strategy as it promotes physical and emotional wellbeing. A structured routine helps maintain stability and reduces the risk of returning to substance use.

B. Prevent overscheduling and becoming fatigued and exhausted. Reach out to reconnect with old buddies to test strength in resistance This statement includes potential triggers for relapse (reconnecting with old buddies) and does not align with effective relapse prevention strategies.

C. Have a friend or counselor number to call when having doubts This is a valuable strategy as it provides the client with a support system and someone to reach out to during moments of doubt or vulnerability.

D. Attend outpatient and community support groups for addiction Support groups provide a sense of community, understanding, and accountability for individuals in recovery. They offer a safe space to share experiences and coping strategies, making them an essential part of relapse prevention.

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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 is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. What information should be included in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

The nurse is building a discharge teaching plan with a client diagnosed with substance use disorder. Which of the following relapse prevention strategies will be included in the teaching? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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