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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 observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?
- A. "It will help you feel better if you talk about it."
- B. "I'll come back when you feel like talking."
- C. "I'll stay with you a few minutes."
- D. "Coming with me to the day room will take your mind off your troubles."
Correct Answer: C
Rationale: Staying with the client provides support without pressuring them to talk.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
- A. Encouraging client feedback about satisfaction with the facility experience
- B. Explaining unit rules and policies regarding unacceptable behaviors
- C. Supporting the client’s wish to refuse prescribed medications
- D. Making sure the client understands expectations for participation
Correct Answer: C
Rationale: The correct answer is C: Supporting the client’s wish to refuse prescribed medications. Autonomy refers to the client's right to make their own decisions about their care. By supporting the client's wish to refuse medications, the nurse is respecting the client's autonomy and right to make decisions about their treatment. This empowers the client to have control over their own healthcare decisions.
Explanation for incorrect choices:
A: Encouraging client feedback about satisfaction with the facility experience - This choice relates to client satisfaction but does not directly address autonomy.
B: Explaining unit rules and policies regarding unacceptable behaviors - This choice focuses on rules and policies, not autonomy.
D: Making sure the client understands expectations for participation - This choice is about ensuring understanding, not necessarily autonomy.
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?
- A. Watching a video with a group in the day room
- B. Walking with the nurse in the courtyard
- C. Participating in a basketball game in the gym
- D. Joining a group discussion about a local election
Correct Answer: B
Rationale: The correct answer is B: Walking with the nurse in the courtyard. During the manic phase, individuals with bipolar disorder may have high energy levels and increased impulsivity. Walking in the courtyard with the nurse provides a safe outlet for physical activity and helps to channel excess energy in a constructive manner. This activity also allows for one-on-one interaction, which can help the client focus and reduce boredom. Other options like watching a video with a group or participating in a basketball game may be too stimulating and could exacerbate manic symptoms. Joining a group discussion about a local election might be overwhelming and less effective in managing the client's energy level and attention.
A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
- A. "So, it seems that you feel responsible for what happened to your mother."
- B. "Your mother will be fine. You shouldn't worry so much."
- C. "Why do you blame yourself? You could not have prevented the stroke."
- D. "You are not responsible for your mother's stroke, but many people in your situation feel this way."
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A is the correct response because it acknowledges the son's feelings without dismissing or invalidating them. It shows empathy and understanding towards his guilt, opening up a conversation for further exploration of his emotions. It reflects active listening and validates his concerns.
Summary of Incorrect Choices:
B: This response minimizes the son's feelings and does not address his sense of guilt, which can further exacerbate his emotional distress.
C: While this response provides reassurance, it does not address the son's feelings of guilt and may come off as dismissive.
D: This response acknowledges the son's feelings but does not directly validate his sense of responsibility, missing an opportunity for therapeutic communication.
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?
- A. Visual hallucination
- B. Gustatory hallucination
- C. Command hallucination
- D. Tactile hallucination
Correct Answer: C
Rationale: The correct answer is C: Command hallucination. This is the priority because command hallucinations can pose a direct threat to the client or others if the commands are harmful or dangerous. Addressing command hallucinations promptly is crucial to ensure the safety of the client and those around them. Visual hallucinations (A) may not necessarily lead to immediate harm. Gustatory hallucinations (B) involve taste sensations and are not typically associated with imminent danger. Tactile hallucinations (D) involve false perceptions of touch and are also less likely to result in immediate harm compared to command hallucinations.