Nokea
The nurse correctly informs the caller that most people have which physical signs after recent marijuana use? Select all that apply.
- A. Shivering
- B. Inflamed eyes
- C. Rapid pulse
- D. Restlessness
- E. Pinpoint pupils
- F. Increased sex drive
Correct Answer: B,C,D
Rationale: Recent marijuana use commonly causes inflamed (red) eyes due to vasodilation, rapid pulse from cardiovascular stimulation, and restlessness from its psychoactive effects.
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The new nurse is working with the cognitively impaired client who has a history of violent behavior. Which statement made by the new nurse reflects an immediate need for follow-up by the mentor?
- A. “My first concern is the safety of all those on the unit.”
- B. “I know to turn off the television when the client starts pacing the floor.”
- C. “When the client started getting aggressive I tried talking the client down.”
- D. “I’m going to try and assign the same staff to work with the client each shift.”
Correct Answer: C
Rationale: Talking during aggression (C) adds stimuli and requires mentor follow-up. Safety focus (A) reducing stimuli (B) and consistent staff (D) are appropriate.
The 19-year-old is given a court order to enter treatment for cocaine abuse. The client threatens to leave the treatment facility AMA. Which statement by the nurse demonstrates an accurate understanding of the client’s options?
- A. “The client is of legal age and can leave on his own will; we can’t stop him from leaving.”
- B. “Due to the court order the client is not allowed to leave and will be placed in seclusion.”
- C. “The client is allowed to leave as long as the court is informed; I’ll prepare the documents.”
- D. “The client cannot leave and will be returned to treatment or another option by court order.”
Correct Answer: D
Rationale: Court-ordered clients cannot leave voluntarily (D). Age (A) is irrelevant seclusion (B) is illegal informing court (C) doesn’t allow leaving.
The client often avoids talking about cocaine use by refocusing on other problems such as losing a job and family discord. Which is the most helpful response by the nurse when the client avoids discussing using cocaine?
- A. “Has your cocaine use helped you to cope with these problems in the past?”
- B. “You need to consider that all these problems are related to your cocaine use.”
- C. “How do you think these problems will change once you no longer use cocaine?”
- D. “You can’t do anything about these while here. Just focus on getting off of cocaine.”
Correct Answer: C
Rationale: Linking drug use to problems (C) builds insight. Coping (A) is inaccurate opinions (B) cause defensiveness and avoiding issues (D) is unhelpful.
Which assessment finding by the nurse is most suggestive to the obese client is taking dextroamphetamine (Dexedrine) at this time?
- A. The client stares blankly into space.
- B. The client monopolizes the discussions.
- C. The client wears sunglasses indoors.
- D. The client slurs words when speaking.
Correct Answer: B
Rationale: Monopolizing discussions reflects the hyperactivity and talkativeness associated with stimulant use like dextroamphetamine.
The nurses critique a chart entry that says, 'States, I feel unwanted." Appears to be confused.' Which statement best describes why this entry is unsatisfactory?"
- A. The nurse who made the entry failed to interpret the significance of feeling unwanted.
- B. The nurse who made the entry failed to indicate the importance of the client's statement.
- C. The nurse who made the entry failed to substantiate that the client made the quote.
- D. The nurse who made the entry failed to describe the evidence of the confused behavior.
Correct Answer: D
Rationale: Failing to describe specific behaviors supporting 'confused' makes the entry vague, reducing its clinical usefulness.