A 24-year-old woman comes to the emergency department, stating "I feel restless. Everything I look
at wavers. Sometimes I am outside my body looking at myself. I can hear colors. I think I am losing
my mind.".
Vital signs are slightly elevated. The nurse should suspect
a. a schizophrenic episode.
b. cocaine overdose.
c. PCP intoxication.
d. LSD ingestion.
D
The client who is high on lysergic acid diethylamide (LSD) often experiences synesthesia (visions in
sound), depersonalization, and concerns about going "crazy.". Option A: Synesthesia is not common
in schizophrenia. Option B: CNS stimulant overdose more commonly involves elevated vital signs
and assaultive, grandiose behaviors. Option C: Phencyclidine (PCP) use commonly causes bizarre or
violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.
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The nurse is working with a patient who has revealed to the nurse that she hits her toddler with a wooden paddle when she is angry. When the child visits, the nurse sees bruises and welts on the child's legs
The patient asks the nurse not to tell anyone because she is ashamed and afraid the child will be taken away from her. What is the most appropriate response by the nurse? 1. "I won't tell anyone. HIPAA protects this information." 2. "I will not report this if you sign a contract stating that you won't hit the child again." 3. "I will have to report this because it is my legal obligation to do so as a nurse." 4. "I will refer you to social services so they can discuss it with you."
The primary level of preventive health care focuses on which topic?
1) Health promotion 2) Early detection 3) Promotion intervention 4) End-of-life care
According to Kerfoot, a leader dictates to those under his guidance
Indicate whether this statement is true or false.
The nurse suspects that a patient is experiencing a local inflammatory response. What finding would support this conclusion? Select all that apply.
A. Functional impairment B. Edema C. Increased platelets D. Heat at the site of injury E. Temperature under 96.8°F (36°C)