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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason:
Aspiration is a significant risk for clients with acute alcohol intoxication due to an impaired gag reflex. Alcohol can depress the central nervous system, leading to a decreased level of consciousness and a diminished gag reflex, which increases the risk of aspiration of gastric contents into the lungs.
Choice B Reason:
Impaired coordination and judgment are common in acute alcohol intoxication, increasing the risk of injury. Alcohol affects the cerebellum, the part of the brain that regulates coordination and balance, as well as the frontal lobes, which are responsible for judgment and decision-making.
Choice C Reason:
Alcohol is metabolized by the liver, and excessive alcohol intake can lead to alcohol toxicity and liver impairment. Acute alcohol intoxication can cause hepatic steatosis, alcoholic hepatitis, and even acute liver failure in severe cases.
Choice D Reason:
Dizziness and an unsteady gait are direct effects of alcohol's impact on the vestibular system and the brain's ability to process spatial information, leading to an increased risk of falls.
Choice E Reason:
Alcohol intoxication can impair immune function, making the client more susceptible to infections. Alcohol disrupts immune pathways in complex ways, which can impair the body's ability to defend against infections
Correct Answer is B
Explanation
Choice A: "I can't call a doctor in the middle of the night unless it's an emergency."
This response may seem reasonable, but it could escalate the situation if the client feels their concerns are not being taken seriously. It's important to validate the client's feelings and find a solution that respects both their needs and the realities of the situation.
Choice B: "You must be very upset about something."
This response validates the client's feelings and opens up a dialogue. It shows empathy and understanding, which can help de-escalate the situation.
Choice C: "Go back to your room, and I'll try to get in touch with your doctor."
This response acknowledges the client's request and provides a clear action plan. However, it's important to follow through on this promise to maintain trust.
Choice D: "You are being unreasonable, and I will not call your doctor at this hour."
This response is confrontational and likely to escalate the situation. It's important to remain calm and professional, even when dealing with difficult behavior.
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