Nokea
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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Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A nurse is assigning a room to a client who is experiencing a manic episode. Which of the following is the most appropriate room selection?
- A. A room adjacent to the nursing station
- B. A room without a window
- C. A room with dim lighting
- D. A room containing personal belongings
Correct Answer: A
Rationale: A room close to the nursing station allows for close monitoring and quick intervention if necessary.
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
- A. Disclose some personal information to the client to demonstrate approachability.
- B. Wait for the client to initiate interaction.
- C. Approach the client frequently throughout the day for brief interactions.
- D. Adopt a neutral attitude when providing care.
Correct Answer: D
Rationale: The correct answer is D: Adopt a neutral attitude when providing care. This approach is appropriate because it helps to build trust with a suspicious client by not evoking any feelings of threat or manipulation. By maintaining a neutral attitude, the nurse can establish a safe and non-threatening environment for the client to gradually open up and develop a therapeutic relationship.
Other choices are incorrect because:
A: Disclosing personal information may blur professional boundaries and make the client more suspicious.
B: Waiting for the client to initiate interaction may prolong the time it takes to establish a connection.
C: Approaching the client frequently may overwhelm the client and reinforce their suspicions.
E, F, G: These options are not provided in the question, so they cannot be evaluated.
A school nurse is speaking to the mother of a 16-year-old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?
- A. "His favorite teacher committed suicide a few weeks ago."
- B. "He has slept 9 hours each night for the past 2 years."
- C. "He is very religious and attends services twice a week."
- D. "He spends much of his time with his two school friends."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The statement "His favorite teacher committed suicide a few weeks ago" indicates exposure to suicide, which is a risk factor for suicidal behavior. This experience can trigger feelings of hopelessness and increase the risk of suicide in adolescents. The mother's concern in this context is valid and should be taken seriously.
Summary:
B: Sleeping 9 hours each night for the past 2 years is not a direct indicator of suicide risk. While changes in sleep patterns can be a sign of depression, it is not as specific as exposure to suicide.
C: Being religious and attending services twice a week is not necessarily an indicator of suicide risk. Religious beliefs can provide comfort and support.
D: Spending time with friends is generally a positive sign of social connectedness, which can be protective against suicide.
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?
- A. Acute pancreatitis
- B. Slowed breathing
- C. Nasal septum perforation
- D. Permanent short-term memory loss
Correct Answer: B
Rationale: Heroin depresses the central nervous system, leading to respiratory depression.