A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?

The correct answer is choice d. “St. John’s wort can reduce the effectiveness of oral contraceptives.”

Choice A rationale:

St. John’s wort is commonly used to treat mild to moderate depression. It has been shown to be effective in alleviating symptoms of depression, likely due to its impact on neurotransmitters like serotonin.

Choice B rationale:

There is no evidence to suggest that St. John’s wort can lower prostate-specific antigen (PSA) levels. PSA levels are typically monitored for prostate health, and St. John’s wort does not have an impact on these levels.

Choice C rationale:

St. John’s wort does not increase estrogen levels in the body. It primarily affects neurotransmitters and has no known effect on hormone levels.

Choice D rationale:

St. John’s wort can indeed reduce the effectiveness of oral contraceptives. It induces certain liver enzymes that can increase the metabolism of contraceptive hormones, thereby reducing their effectiveness and increasing the risk of unintended pregnancy.

Choice A rationale:

Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.

Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.

Choice C rationale:

Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.

A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.

Choice D rationale:

Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.

A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.

Choice B rationale:

Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.

A thorough nutritional assessment should include:

A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.

A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.