A patient is thin, tense, jittery, and has dilated pupils. The patient says, "I'm burning up. I need help.". The patient allows a temperature to be taken (it is 104° F), then becomes suspicious and says, "You could be trying to kill me."
The patient refuses further examination. Abuse of which substance is most likely? a. PCP
b. Heroin
c. Barbiturates
d. Amphetamines
D
The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.
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The nurse working a rape telephone hotline should focus the call so as to
a. provide the caller with a sympathetic listener. b. provide the immediate steps the victim may take. c. arrange long-term client counseling. d. obtain information to relay to the local police.
The nurse is providing palliative nutrition to a client with a terminal illness. Which intervention should the nurse include on the client's plan of care?
a. Scheduled rest periods b. Mouth care and lip lubrication c. A regular balanced diet with snacks d. Range-of-motion exercises every 4 hours
A nurse is educating an adult patient on patient rights, according to the American Hospital Association. The teaching has been effective when the adult states that the patient's rights in-clude:
a. "choice of diet to be eaten during hospita-lization.". b. "considerate and respectful care from all care providers.". c. "medical care regardless of ability to pay.". d. "information from nurses about diagnosis and prognosis.".
The best way for the nurse to show cultural sensitivity when addressing the personal questions required of the nursing history is to:
1. Break the assessment into shorter intervals and discuss general topics first. 2. Thoroughly explain the reason for asking many questions before beginning the assessment. 3. Pick a time when the family is present and can help with the admission assessment questions. 4. Wait until the nurse-client relationship has been established.