A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.
The client has prescriptions for an anxiolytic and an SSRI antidepressant.
Which of the following precautions should the nurse take?
Implement 24-hr one-to-one nursing observation.
Document the client's behavior every 2 hr.
Restrict interactions with other clients.
Administer prescribed medication via the IM route.
The Correct Answer is A
Choice A rationale
Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm.
Choice B rationale
Documenting the client's behavior every 2 hr is not sufficient to ensure their safety in an overdose situation.
Choice C rationale
Restricting interactions with other clients does not directly address the immediate risk of harm to the client.
Choice D rationale
Administering prescribed medication via the IM route does not provide the necessary supervision for a client at high risk of self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Scheduling long teaching sessions is not effective for older adults, as it can lead to fatigue and decreased attention. Short, focused sessions are more beneficial to promote participation and information retention among older adults, who may have limitations in concentration and stamina.
Choice B rationale
Using "I" statements rather than "you" statements helps build rapport and reduces defensiveness. It fosters a supportive learning environment by focusing on the instructor's perspective and experiences, making the communication more personal and less confrontational.
Choice C rationale
Assisting clients in establishing long-term goals is important but not the primary method to eliminate learning barriers. Effective teaching strategies for older adults should prioritize immediate and relevant information that can be easily understood and applied, rather than focusing solely on long-term planning.
Choice D rationale
Ensuring teaching sessions occur right before bedtime is not advisable for older adults, as they may be tired and less receptive to new information. Optimal learning times should be chosen based on the clients' energy levels and alertness, typically earlier in the day.
Correct Answer is D
Explanation
Choice A rationale
Relaxation exercises can help manage anxiety but are not the immediate first action required for a newly admitted client.
Choice B rationale
Explaining response prevention is useful for OCD treatment but isn't the first priority upon admission.
Choice C rationale
Administering medication can alleviate anxiety symptoms but isn't the first action that establishes a comprehensive assessment.
Choice D rationale
Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.