Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Determine the client’s reason for attempting suicide.

Obtain the client’s serum hydrocodone/acetaminophen level.

Encourage the client to increase fluid intake.

Observe the client for further narcotic effects.

Answer and Explanation

The Correct Answer is D

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

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Correct Answer is A

Explanation

A. Supporting the client to list small behavioral changes is a person-centered and achievable approach to promote progress.
B. Explaining specific skills needed to prevent a relapse may be overwhelming at this early stage.
C. Providing teaching on symptoms of substance use dependence may not be the most immediate and practical response to the client's expressed desire for positive change.
D. Advising the client to reschedule until committing to recovery is not supportive and may discourage the client's motivation for positive change.

A. Participates in individual and group therapy. B. Demonstrates effective ways to cope with anxiety. C. Takes all antianxiety medications as prescribed. D. Learns methods of relaxation to reduce anxiety.

Correct Answer is B

Explanation

A. Participating in individual and group therapy is important for overall mental health, but the immediate focus is on addressing the self-harming behavior.
B. Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
C. Taking all antianxiety medications as prescribed is important but may not directly address the client's self-harming behavior.
D. Learning methods of relaxation is valuable, but the most immediate concern is preventing self-harm. The client should demonstrate effective ways to cope with anxiety to reduce the risk of self-injury.

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Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is B

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