An adult in the emergency department states, "Everything I see waves. I am outside my body looking at myself. I think I'm losing my mind.". Vital signs are slightly elevated. The nurse should suspect:
a. a schizophrenic episode.
b. opium intoxication.
c. cocaine overdose.
d. LSD ingestion.
D
The patient who is high on lysergic acid diethylamide (LSD) often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy.". Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.
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The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?
a. Burn b. Laceration c. Pressure ulcer d. Infection
After completing a health assessment of the client, which information would the nurse need to document in the progress notes as opposed to on the assessment form?
1. Any findings that deviate from expected or normal findings 2. Detailed follow-up examination of findings that deviate from expected or normal findings 3. All findings of the health assessment 4. Nothing, because everything would be documented on the assessment form
A patient taking risedronate IR [Actonel] for osteoporosis reports experiencing diarrhea and headaches. What will the nurse tell this patient?
a. These are common side effects of this drug. b. These symptoms indicate serious toxicity. c. The patient should discuss taking risedro-nate DR [Atelvia] with the provider. d. The medication should be taken after a meal to reduce symptoms.
A person whose spouse died 2 years earlier tells friends, "I think I'll begin to go out socially, maybe even take someone to dinner." This comment best demonstrates that the individual is:
a. denying the significance of the loss. b. in a period of resolution of grief. c. actively working through grief. d. experiencing intrusion.