Practice Question
A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me.". The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
Answer Choices:
Correct Answer:
Opium.
Rationale:
🔴 The client’s tachycardia and hypertension, along with the statement, "People are out to get me", suggest acute toxicity from a stimulant or opioid.
🔴 Opium (or other opioids) can lead to delirium and paranoia, as well as the tachycardia and hypertension seen in this case.
🔴 Substance-induced paranoia is often seen with stimulants or drugs like cocaine and amphetamines, but in this case, the combination of symptoms aligns with opioid toxicity.
🔴 The nurse should monitor the client for other signs of opioid overdose and be prepared to administer naloxone if indicated.
🔴 This condition requires immediate intervention to prevent further complications such as respiratory depression or cardiovascular collapse.
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This question is from RN ATI Mental Health-2019 NGN II which contains 69 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Mental Health
- Answer Choices: 3