A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 minutes ago.
The client is lethargic and has a respiratory rate of 10/min.
After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?
Evaluate the client for further suicidal behavior.
Administer flumazenil to the client.
Monitor the client's IV site for thrombophlebitis.
Initiate seizure precautions for the client.
The Correct Answer is B
= Answer is... Choice B. Administer flumazenil to the client.
Choice A rationale:
In the emergency department scenario described, the client has presented with symptoms suggestive of a diazepam overdose, indicating potential suicidal behavior. However, while evaluating the client for further suicidal behavior is an important aspect of comprehensive care, it is not the immediate priority in this situation. The client's lethargy and respiratory depression require urgent intervention to reverse the effects of diazepam overdose and stabilize their condition. Once the client's immediate medical needs are addressed, further assessment and intervention regarding suicidal behavior can be pursued as part of ongoing care and safety planning.
Choice B rationale:
Administering flumazenil to the client is the most appropriate next action in the management of a diazepam overdose. Flumazenil, a benzodiazepine receptor antagonist, effectively reverses the sedative effects of benzodiazepines such as diazepam by competitively blocking benzodiazepine binding sites on the gamma-aminobutyric acid (GABA) receptor complex. By antagonizing the effects of diazepam, flumazenil can rapidly restore consciousness and respiratory drive in clients experiencing benzodiazepine-induced central nervous system depression, such as lethargy and hypoventilation. Prompt administration of flumazenil is crucial for preventing further respiratory compromise and potential respiratory arrest in overdose situations.
Choice C rationale:
Monitoring the client's IV site for thrombophlebitis is an important aspect of nursing care during IV therapy; however, it is not the immediate priority in this scenario. While maintaining IV access is essential for administering medications and fluids, including flumazenil in this case, the urgent need to reverse the effects of diazepam overdose takes precedence over monitoring for IV complications. Thrombophlebitis can be assessed and managed concurrently with the administration of flumazenil and other aspects of the client's care once their immediate medical condition is stabilized.
Choice D rationale:
Initiating seizure precautions for the client may be warranted in certain clinical situations, particularly if the client has a history of seizures or if there are concerns about potential withdrawal or rebound seizures following the administration of flumazenil. However, in the context of a diazepam overdose with central nervous system depression and lethargy, the primary focus is on reversing the effects of the overdose and restoring respiratory function. Seizure precautions can be implemented if indicated based on ongoing assessment and clinical judgment but are not the immediate next action following initiation of IV access and administration of flumazenil.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Determine any physical signs of injury.
Choice A rationale:
Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.
Choice B rationale:
Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.
Choice C rationale:
Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.
Choice D rationale:
Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.
Correct Answer is D
Explanation
Choice A rationale:
Metallic taste in mouth. Metallic taste in the mouth is a common side effect of many medications, including sertraline. It occurs due to the medication's effect on taste receptors. Patients should be informed about this side effect, but it is not a serious adverse effect that requires immediate medical attention.
Choice B rationale:
Increased urinary frequency. Increased urinary frequency is not a commonly reported side effect of sertraline. While some individuals may experience changes in urination patterns, it is not a significant adverse effect associated with this medication.
Choice C rationale:
Dry cough. Dry cough is not a known side effect of sertraline. Cough can occur due to various reasons, such as allergies, respiratory infections, or other medications, but it is not directly caused by sertraline.
Choice D rationale:
Excessive sweating. Excessive sweating, also known as hyperhidrosis, is a potential adverse effect of sertraline. It can be bothersome for some individuals and may impact their quality of life. Patients should be aware of this side effect and report it to their healthcare provider if it becomes bothersome or persistent.
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