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A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?
- A. Nystagmus
- B. Dilated pupils
- C. Hypersomnia
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Dilated pupils. Cocaine intoxication typically presents with dilated pupils due to the drug's stimulant effects on the sympathetic nervous system. This causes pupil dilation by increasing the release of norepinephrine. Nystagmus (choice A) is not a common finding in cocaine intoxication. Hypersomnia (choice C) is unlikely as cocaine is a stimulant that often leads to decreased need for sleep. Depression (choice D) is not a typical symptom of cocaine intoxication. In summary, dilated pupils are a key indicator of cocaine intoxication, while nystagmus, hypersomnia, and depression are not characteristic findings.
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A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?
- A. Turn on a dance video so the client can burn off excess energy.
- B. Offer the client a low-calorie snack in return for stopping the behavior.
- C. Walk the client outside and sit with her in the garden area.
- D. Observe the client closely for the development of aggressive behavior.
Correct Answer: C
Rationale: The correct answer is C: Walk the client outside and sit with her in the garden area. This intervention helps the client to redirect their energy in a positive and calming manner. Being outdoors can provide a change of environment, fresh air, and can help the client feel more grounded. It also offers a distraction from the impulsive behavior and promotes relaxation. Turning on a dance video (choice A) may further stimulate the client's behavior rather than calming them down. Offering a snack (choice B) may reinforce the behavior and is not addressing the underlying issue. Observing for aggressive behavior (choice D) is important but does not actively address the client's current behavior.
A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?
- A. "Everyone feels better after showering."
- B. "You must be getting better. You look great!"
- C. "I see you have done some grooming today."
- D. "Why are you all dressed up today? Is it a special occasion?"
Correct Answer: C
Rationale: A neutral, observational statement acknowledges the client’s effort without assuming improvement.
A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
Correct Answer: A
Rationale: Persecutory delusions involve irrational beliefs that one is being targeted or harmed by external forces.
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me.” The nurse identifies this behavior as an example of which of the following defense mechanisms?
- A. Dissociation
- B. Introjection
- C. Regression
- D. Repression
Correct Answer: C
Rationale: The correct answer is C: Regression. Regression is a defense mechanism where an individual reverts to an earlier stage of development when faced with stressful situations. In this scenario, the client's behavior of being consistently late and avoiding responsibilities reflects a regression to a state where they feel the need to be taken care of, like a child seeking comfort from a caregiver. This behavior is a way of coping with anxiety by seeking refuge in a familiar and less demanding role. Dissociation (A) involves disconnecting from reality to avoid distress, introjection (B) is internalizing the qualities of others, and repression (D) is unconsciously suppressing unwanted thoughts or memories.
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
- A. Leaves the child's room exactly as it was before the loss
- B. Volunteers at a local children's hospital
- C. Talks about the child in the past tense
- D. Visits the child's grave every week after worship services
Correct Answer: A
Rationale: In prolonged grief, individuals may struggle to move forward and avoid changing their environment.