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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Research consistently shows that individuals who have a history of violent behavior are at a higher risk of engaging in future violent acts. This is a significant predictor because past behavior is often indicative of future behavior. Individuals with a history of violence may have difficulty managing anger, frustration, or stress, making them more prone to aggressive tendencies in various situations.

Choice B rationale:

Experiencing delusions refers to having false beliefs that are firmly held despite evidence to the contrary. While delusions can lead to erratic behavior, not all individuals experiencing delusions will become violent. The presence of delusions alone is not as strong a predictor of future violence as a documented history of violent behavior.

Choice C rationale:

While statistical data may indicate that males are more commonly involved in violent crimes, it is important to note that gender alone is not a reliable predictor of an individual's likelihood to become violent. Many males never engage in violent behavior, and focusing solely on gender overlooks crucial individual factors that contribute to violent tendencies.

Choice D rationale:

Having a history of being in prison suggests past involvement in criminal activities, but it does not directly predict future violent behavior. Some individuals may have been incarcerated for non-violent offenses or may have undergone rehabilitation, reducing their propensity for violence. Therefore, this choice is not as strong a predictor as previous violent behavior.

A. Obtain the specimen immediately upon the client waking up. B. Ask the client to provide 15 to 20 mL of sputum into the container. C. Wear sterile gloves to collect the specimen from the client. D. Wait 1 day to collect the specimen if the client cannot provide sputum.

Correct Answer is A

Explanation

The correct answer is Choice a.

Choice a rationale: The nurse should obtain the specimen immediately upon the client waking up, as sputum from deep in the lungs is usually more easily collected at this time. Sputum collected upon waking up is more likely to contain secretions from the lower respiratory tract, providing a better sample for tuberculosis diagnosis. This timing maximizes the chance of detecting the bacteria.

Choice b rationale: Choice b is incorrect because the typical volume of sputum needed for testing is about 1 teaspoon (5 mL), not 15 to 20 mL. Collecting such a large volume could be challenging for the client and unnecessary for diagnostic purposes.

Choice c rationale: Choice c is incorrect because while gloves should be worn, they do not need to be sterile, just clean. The use of clean gloves is sufficient to prevent contamination during specimen collection, and sterile gloves are not required for this procedure.

Choice d rationale: Choice d is incorrect because it’s important to try to collect the specimen as soon as possible, not wait a full day. Delaying collection for a day could result in a missed opportunity to diagnose tuberculosis and initiate appropriate treatment promptly. Collecting the specimen promptly maximizes the accuracy of diagnostic testing and facilitates timely intervention for the client's health.

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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?

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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?