A nurse is teaching the parents of a school-age child who has ADHD about atomoxetine. Which of the following instructions should the nurse include in the teaching?

Choice A Reason:

When a client with a personality disorder engages in self-destructive behavior, it is crucial for the staff to observe this behavior closely to ensure the safety of both the client and others around them. Self-destructive behaviors can include actions such as self-harm, substance abuse, or reckless activities that pose a significant risk to the individual’s well-being. By monitoring these behaviors, staff can intervene promptly to prevent harm and provide necessary support. Ensuring safety is a fundamental aspect of care in mental health settings, as it helps to stabilize the client and create a secure environment for their treatment and recover.

Choice B Reason:

Indulging the client’s wishes is not a recommended approach when dealing with self-destructive behavior. While it is important to understand and validate the client’s feelings, indulging their wishes can reinforce negative behaviors and hinder their progress towards healthier coping mechanisms. Instead, staff should focus on providing appropriate interventions and support that address the underlying issues contributing to the self-destructive behavior. This approach helps the client develop more constructive ways of meeting their needs and managing their emotions.

Choice C Reason:

While self-destructive behavior may provide a temporary outlet for feelings of anger and frustration, it is not a healthy or sustainable way to cope with these emotions. Encouraging or allowing such behavior can lead to further harm and exacerbate the client’s mental health issues. Staff should work with the client to identify and implement healthier coping strategies that effectively address their emotional needs without causing harm. This can include therapeutic interventions, counseling, and skills training to help the client manage their anger and frustration in more constructive ways.

Choice D Reason:

Assuming responsibility for the client’s behavior is not an effective way to reduce their anger and anxiety. In fact, it can create a dependency on staff and prevent the client from developing their own coping skills and sense of autonomy. It is important for staff to support the client in taking responsibility for their actions and learning how to manage their emotions independently. This empowerment is a key component of the therapeutic process and contributes to the client’s long-term recovery and well-being.

The correct answer is b. Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.

Choice A Reason: Get the defibrillator to the patient’s bedside and open the crash cart

While having the defibrillator and crash cart ready is important in emergency situations, it is not the immediate priority in this scenario. The patient’s symptoms suggest opioid overdose, which requires immediate intervention to support breathing and reverse the effects of the opioid. The primary focus should be on ensuring adequate oxygenation and administering naloxone.

Choice B Reason: Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone

This is the correct answer. The patient’s blue-tinged lips, slowed respirations, and pinpoint pupils are indicative of opioid overdose. Administering oxygen via a 100% nonrebreather mask helps to ensure adequate oxygenation, while placing an IV catheter allows for the administration of naloxone, an opioid antagonist that can reverse the effects of the overdose. This intervention addresses the immediate life-threatening condition.

Choice C Reason: Administer naloxone intranasally if there is not an IV catheter in place

While administering naloxone intranasally is an appropriate alternative if IV access is not available, it is not the first priority. The initial focus should be on ensuring adequate oxygenation and establishing IV access for more effective administration of naloxone. If IV access cannot be quickly established, then intranasal naloxone can be used.

Choice D Reason: Contact the patient’s parents or legal guardian for consent to treat

Obtaining consent is important, but it is not the immediate priority in a life-threatening situation. The nurse’s primary responsibility is to stabilize the patient and address the acute medical emergency. Once the patient is stabilized, the nurse can then contact the parents or legal guardian for further consent and information.