A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority?
Neurological
Respiratory
Hepatic
Cardiovascular
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient.
B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way.
C. This is judgmental and blaming, which is not therapeutic and may increase hostility.
D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.
Correct Answer is D
Explanation
A. Neuroleptic malignant syndrome is a rare, life-threatening reaction associated with antipsychotic medications, not stimulants like methylphenidate.
B. Dystonia, akinesia, and extrapyramidal symptoms are primarily seen with antipsychotic use, not with ADHD stimulant medications.
C. Bradycardia and hypotensive episodes – Stimulants more commonly cause tachycardia and hypertension, not bradycardia or hypotension.
D. Sleep disturbances and weight loss are common side effects of methylphenidate due to its stimulant properties. Monitoring sleep patterns, appetite, and growth is a priority in children taking this medication.
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