An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?
The drug that was ingested.
The time since drug ingestion.
Reason for the suicide attemp
Past history of depression.
The Correct Answer is A
Choice A rationale: A. The drug that was ingested is the most important information because knowing the specific substance determines the course of treatment. For example, acetaminophen overdose requires administration of N-acetylcysteine, while opioid overdose requires naloxone. Different drugs have different toxic effects, antidotes, and supportive measures, making this information critical to providing appropriate and potentially life-saving care.
Choice B rationale: The time since drug ingestion is important because many interventions, such as gastric lavage or activated charcoal, are time-sensitive. However, without knowing the specific drug, it is difficult to determine whether these interventions are necessary or effective
Choice C rationale: Knowing the reason for the suicide attempt is important for overall assessment and treatment planning but may not provide immediate information for the current situation.
Choice D rationale: Past history of depression is relevant to the client's overall mental health, but in the context of a suspected drug overdose, the time since ingestion takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.
Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.
Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.
Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.
Correct Answer is C
Explanation
Choice A rationale: Providing teaching on the symptoms of substance use dependence may be appropriate, but supporting the client's desire for positive changes is the immediate priority.
Choice B rationale: Advising the client to reschedule is not supportive of their current motivation for change.
Choice C rationale: Supporting the client to list small behavioral changes needed aligns with the client's expressed desire for a healthier lifestyle and is consistent with motivational interviewing techniques.
Choice D rationale: Explaining specific relapse prevention skills may be useful later in the recovery process, but initially supporting the client's motivation for change is the priority.
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