A nurse is caring for a client who has been admitted with a suspected stimulant overdose. Which of the following nursing priorities should the nurse implement first?

A: Administer activated charcoal to the client.

B: Obtain a urine sample from the client for drug testing.

C: Initiate seizure precautions for the client.

D: Monitor vital signs frequently.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Administering activated charcoal can be a treatment option in some overdose cases, particularly when the substance ingested is known to be adsorbed by charcoal. However, its effectiveness varies depending on the substance and the timing of administration post-ingestion. In the case of a stimulant overdose, activated charcoal is not the first-line treatment, especially when the specific stimulant and time of ingestion are unknown.

Choice B Reason:
Obtaining a urine sample for drug testing is important for confirming the type of stimulant ingested and can guide further treatment. However, this is not the immediate priority in an acute overdose situation where the patient's life may be at risk.

Choice C Reason:
Initiating seizure precautions is important in the management of stimulant overdose due to the risk of seizures¹. However, this is a precautionary measure and not the first action to take. The initial focus should be on assessing and stabilizing the patient's vital functions.

Choice D Reason:
Monitoring vital signs is the most critical initial step in managing a suspected stimulant overdose. Stimulants can cause severe hypertension, tachycardia, hyperthermia, and arrhythmias. Frequent monitoring allows for the early detection of life-threatening conditions and the initiation of appropriate interventions to stabilize the patient's condition.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:
Enrolling the client in a nutritional class can be beneficial for long-term nutritional education, but it may not have an immediate impact on the client's current state of malnutrition and may not be feasible if the client is experiencing severe symptoms of depression.

Choice B reason:
Weighing the client at the same time every morning is a good practice for monitoring the client's weight, but it does not directly contribute to improving the client's nutritional status. It is more of a measurement and monitoring action rather than an intervention.

Choice C reason:
Arranging a consultation with the facility chaplain might address spiritual needs, which can be an important aspect of holistic care, but it does not directly improve nutritional status and is not the most immediate concern for a client with malnutrition.

Choice D reason:
Sitting with the client during meals and snacks can encourage food intake and provide an opportunity for the nurse to offer support and encouragement. This direct intervention can help improve the client's nutritional intake, which is essential for addressing malnutrition.

A. "Nausea, vomiting, and diarrhea are not a concern while on this medication." B. "You should maintain adequate sodium intake." C. "You will need to take this medication on an empty stomach." D. "You will need your blood levels drawn weekly during the first month."

Correct Answer is ["B","D"]

Explanation

Choice A reason:
This statement is incorrect. Nausea, vomiting, and diarrhea can be side effects of lithium and are concerns while on this medication. It is important for clients to report these symptoms to their healthcare provider, as they can be signs of lithium toxicity.

Choice B reason:
This statement is correct. Maintaining adequate sodium intake is important while taking lithium. Sodium levels can affect lithium levels in the body, and sudden changes in sodium intake can lead to lithium toxicity or decreased effectiveness of the medication.

Choice C reason:
This statement is incorrect. Lithium does not necessarily need to be taken on an empty stomach. It can be taken with or without food, although taking it with food may help reduce stomach upset.

Choice D reason:
This statement is correct. Regular monitoring of blood levels is essential during the first month of lithium therapy to ensure that lithium levels are within the therapeutic range and to avoid toxicity. The frequency of monitoring may change based on the results and as treatment continues.

View Question and Answer

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

A nurse is caring for a client who has been admitted with a suspected stimulant overdose. Which of the following nursing priorities should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an inpatient mental health unit is caring for a client diagnosed with major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

Correct Answer is D

Explanation

A nurse is preparing to teach a client about the lithium prescription for treating bipolar disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)

A client presents with symptoms consistent with factitious disorder. Which of the following hypotheses should the nurse prioritize in the care of this client? (Select all that apply)

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

A nurse is caring for a client after an overdose of OxyContin. The nurse anticipates an order for which medication to reverse the effects of the opioids?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?

A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors?