An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?
Refer the client to the cardiology clinic.
Obtain the client's blood pressure.
Determine if alprazolam was taken recently.
Assess the client for substance abuse.
The Correct Answer is B
Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.
Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.
Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.
Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.
Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.
Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.
Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.