A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority?

Neurological

Respiratory

Hepatic

Cardiovascular

Answer and Explanation

The Correct Answer is B

A. Neurological assessment is important, but not the priority since opioid overdose primarily causes life-threatening respiratory depression.
B. Respiratory assessment is the highest priority because opioids suppress the respiratory center, leading to hypoventilation, hypoxia, or apnea.
C. Hepatic assessment is not the immediate concern in acute overdose.
D. Cardiovascular assessment is necessary, but respiratory status takes precedence because airway and breathing are life-sustaining priorities.

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Correct Answer is B

Explanation

A. Distinguishing between reality and fantasy shows intact cognition, not mental illness.
B. A persistent sad, hopeless mood suggests depression, a hallmark of mental illness when symptoms are severe and ongoing.
C. Occasional anxiety and insomnia can be normal stress responses, not necessarily mental illness.
D. Difficulty making a decision about work is a common life stressor, not a clear sign of mental illness.

A. Respect nurse-patient relationship confidentiality. B. File a written report with the agency's ethics committee. C. Anonymously report the abuse by phone to the local child protection agency. D. Reply, I'm glad you feel comfortable talking to me about it."

Correct Answer is C

Explanation

A. Respecting confidentiality is important, but the nurse has a legal and ethical duty to report child abuse, even if the patient discloses it in confidence.

B. Filing a report with the ethics committee does not fulfill the mandatory reporting requirement for child abuse.

C. The nurse must report suspected or disclosed child abuse to the appropriate child protection agency, even if the patient is now in rehabilitation. Anonymity may be used if allowed, but reporting is legally required.

D. Reassuring the patient about comfort in sharing does not address the immediate need to protect the child and fulfill mandatory reporting obligations.

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A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority?

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Naxlex Comprehensive Predictor Exams

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness? The patient

Correct Answer is B

Explanation

A patient in alcohol rehabilitation reveals to the nurse. "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Select the nurse's most important action.

Correct Answer is C

Explanation

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A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority?

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