The mother of an infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Choice A reason: Lethargy and depression are more typical of cocaine withdrawal or post-use crash, not active use. Recent cocaine use causes stimulation, euphoria, and dilated pupils due to sympathetic activation. These symptoms are less prominent during intoxication, making this incorrect for documenting acute cocaine effects.

Choice B reason: Cocaine, a stimulant, causes sympathetic activation, leading to stimulation (e.g., agitation, euphoria) and dilated pupils. These are hallmark signs of recent use, observable in the client’s presentation. This aligns with toxicology evidence for cocaine intoxication, making it the correct choice for nursing documentation.

Choice C reason: Bradycardia and bradypnea are not associated with cocaine use, which causes tachycardia and increased respiratory rate due to stimulation. These findings suggest opioid effects or other conditions, not cocaine intoxication, making this incorrect for documenting the client’s recent cocaine use observations.

Choice D reason: Hallucinations and delusions may occur with chronic or high-dose cocaine use but are less common than stimulation and dilated pupils in recent use. These psychiatric symptoms are not primary indicators of acute intoxication, making this less accurate for routine documentation of cocaine effects.

Choice A reason: Asking about other children shifts focus from the mother’s expressed depression and does not address her emotional distress or safety. Assessing for suicidal or harmful thoughts is critical given her depression, making this less urgent and incorrect for responding to her immediate emotional state.

Choice B reason: Journaling may help process emotions but does not address the immediate risk of depression-related self-harm or harm to the child. Assessing for suicidal ideation is the priority to ensure safety, making journaling secondary and incorrect for the nurse’s initial response to this mother.

Choice C reason: Asking about thoughts of harming herself or her child is critical, as the mother’s depression raises safety concerns. This assesses suicide or infanticide risk, prioritizing safety in a high-stress caregiving situation, aligning with psychiatric nursing principles for maternal mental health crisis intervention.

Choice D reason: Reassuring about milestones is dismissive of the mother’s grief and depression, potentially minimizing her distress. Assessing for harmful thoughts ensures safety, addressing the immediate risk of her emotional state. False reassurance is untherapeutic, making this incorrect for responding to her depression.