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
No explanation
Correct Answer is A
Explanation
Choice A rationale:
Asking the client directly about the hallucinations is essential in understanding the nature and content of the hallucinations. This information is crucial for the nurse to assess the client's mental state accurately and plan appropriate interventions. Direct communication helps establish trust and rapport with the client, making them more likely to share their experiences.
Choice B rationale:
Avoiding eye contact can create a sense of disconnection and may increase the client's anxiety. Establishing eye contact, on the other hand, communicates empathy and attentiveness, which are essential in therapeutic communication.
Choice C rationale:
Encouraging the client to lie down in a quiet room might not be the most appropriate action, as it does not address the hallucinations directly. It's important to address the hallucinations and help the client cope with them effectively.
Choice D rationale:
Referring to the hallucinations as if they are real might validate the client's experience but can also perpetuate the hallucinations. The nurse should acknowledge the client's feelings without reinforcing the false beliefs. Providing reality-based perspectives and encouraging the client to explore the origin of these hallucinations can be more beneficial.
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