A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, 'Somebody tied me up with ropes.' The patient is experiencing:

Correct Answer: A

Rationale: The correct answer is A: illusion. An illusion is a misinterpretation of a real external stimulus. In this case, the patient is misperceiving the traction as ropes due to the altered mental state from intoxication. It is a sensory distortion based on a real object. Delusion (B) is a fixed false belief, not related to sensory perceptions. Hallucinations (C) are false sensory perceptions without external stimulus. Hypnagogic phenomenon (D) refers to sensory experiences during the transition from wakefulness to sleep, not applicable here.

Correct Answer: A

Rationale: The correct answer is A: Empathetic, supportive. This approach establishes trust, shows understanding, and promotes open communication. Empathy helps build a therapeutic relationship, which is crucial in treating alcohol dependence. Being supportive encourages the patient to feel safe and willing to discuss their issues. Strong, confrontational (B) may lead to resistance and defensiveness. Skeptical, guarded (C) can create barriers and hinder progress. Cool, distant (D) may make the patient feel isolated and unsupported. Overall, empathy and support create a positive and collaborative therapeutic environment.

Correct Answer: A

Rationale: The correct answer is A: Monitor the airway and vital signs every 15 minutes. After administering naloxone to a patient with an opiate overdose, it is crucial to monitor the patient's airway and vital signs regularly to assess for respiratory depression, potential re-sedation, and other adverse effects of naloxone. This intervention ensures the patient's safety and allows for prompt detection and management of any complications. Choice B is incorrect because inserting a nasogastric tube and testing gastric pH is not indicated after naloxone administration for opiate overdose. Choice C is incorrect as treating hyperpyrexia with cooling measures is not a priority intervention in this scenario. Choice D is also incorrect as inserting an indwelling urinary catheter is not necessary after administering naloxone for opiate overdose.

Correct Answer: C

Rationale: The correct answer is C because the assessment findings of nausea, vomiting, diaphoresis, anxiety, and tremors are classic symptoms of withdrawal from central nervous system depressants such as alcohol or benzodiazepines. Nausea and vomiting can result from the body's attempt to expel the toxic substance, diaphoresis can occur due to increased sympathetic activity, anxiety and tremors are common manifestations of central nervous system hyperactivity during withdrawal. The other choices (A, B, D) do not align with the typical withdrawal symptoms of CNS depressants and are more indicative of other conditions or substances.

Correct Answer: A

Rationale: The correct answer is A because for a patient who has ingested LSD, it is important to have someone stay with them and provide verbal support due to the potential for anxiety and panic attacks. This helps in grounding the patient and providing reassurance. On the other hand, for a patient who has ingested PCP, a regimen of limited contact with staff members is maintained to prevent potential aggression or unpredictable behavior. Continual visual monitoring is provided to ensure safety without directly engaging with the patient. Choice B is incorrect because placing a patient on one-on-one intensive supervision for PCP ingestion may escalate the situation due to potential paranoia or aggression. Choice C is incorrect because LSD ingestion may lead to sensory overload, so providing moderate sensory stimulation is more appropriate. Choice D is incorrect because restraints for LSD ingestion are not necessary and seizure precautions are not typically needed for PCP ingestion.