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 ["B","D","E"]
Explanation
Choice A reason:
Regular exercise is generally not considered a predisposing factor for the development of anxiety disorders. In fact, regular physical activity is often recommended as a part of the treatment plan for anxiety because it can help reduce symptoms. Exercise can improve mental health by reducing levels of the body's stress hormones, such as adrenaline and cortisol. It also stimulates the production of endorphins, chemicals in the brain that are the body's natural painkillers and mood elevators.
Choice B reason:
A family history of anxiety disorders can be a predisposing factor. Anxiety disorders can run in families, suggesting that a combination of genes and environmental stresses can produce the disorders. If a close family member has an anxiety disorder, it may increase the likelihood that an individual will develop one as well.
Choice C reason:
Regular meditation practice is typically not a predisposing factor for anxiety disorders; rather, it is often used as a coping mechanism to manage anxiety. Meditation can help reduce stress levels and improve emotional health, which may decrease the risk of developing an anxiety disorder.
Choice D reason:
Being a perfectionist can sometimes be a predisposing factor for anxiety disorders. Perfectionism is often associated with fear of failure, fear of making mistakes, and a tendency to experience high levels of stress and pressure, which can contribute to the development of anxiety disorders.
Choice E reason:
Excessive caffeine consumption can be a predisposing factor for anxiety disorders. Caffeine is a stimulant that can mimic the symptoms of anxiety, such as increased heart rate and nervousness. People who consume large amounts of caffeine may have an increased risk of developing anxiety disorders.
Choice F reason:
Chronic physical illness can be a predisposing factor for anxiety disorders. Living with a chronic illness can cause significant stress and may lead to the development of anxiety disorders. The constant worry about health, treatments, and the future can be overwhelming and may trigger or worsen anxiety symptoms.
Correct Answer is B
Explanation
Choice A reason:
Eating foods high in tyramine is not a risk factor for lithium toxicity. Tyramine is associated with dietary restrictions in patients taking monoamine oxidase inhibitors, not lithium.
Choice B reason:
Engaging in activities that cause excessive sweating, such as running 4 miles outdoors every afternoon, can lead to dehydration. Dehydration is a significant risk factor for lithium toxicity because it can increase lithium levels in the blood, potentially leading to toxicity.
Choice C reason:
Drinking 2 liters of liquids daily is generally recommended for hydration and is not a risk factor for lithium toxicity. Adequate hydration can help prevent lithium toxicity by ensuring that lithium is properly excreted through the kidneys.
Choice D reason:
Eating 2 to 3 grams of sodium-containing foods daily is within normal dietary intake ranges and is not a risk factor for lithium toxicity. Maintaining a consistent sodium intake is important when taking lithium, as low sodium levels can lead to increased lithium retention and potential toxicity.
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