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 A

A.   Determining the client's reason for attempting suicide is the highest priority at this time to understand the underlying issues and plan appropriate interventions.
B.   Obtaining the serum hydrocodone/acetaminophen level is important for assessing the extent of the overdose but is not the immediate priority.
C. Encouraging fluid intake and observing for further narcotic effects are important aspects of care but are not the highest priority after naloxone administration.
D.   Observing for further narcotic effects is important but is not the immediate priority.
Understanding the client's motivation for the suicide attempt takes precedence.

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Correct Answer is D

Explanation

Rationale for A: While seclusion and restraint may be necessary, this should be considered after assessing the environment for immediate safety concerns.

Rationale for B: Administering medication may help calm the client but does not address immediate safety concerns.

Rationale for C: Confirm the client’s identity and orientation to time and place is a therapeutic intervention that helps ground the client during a dissociative episode. However, in a situation where physical aggression is present, ensuring safety takes precedence over reorientation.

Rationale for D. Inspect the area for objects that can be used in a dangerous manner is the first and most critical action. When a client becomes physically aggressive, the nurse's priority is to maintain safety for the client, staff, and others in the environment. Removing or securing potentially harmful objects minimizes the risk of injury and creates a safer setting for subsequent interventions.

A. Encourage the client to weigh herself daily at bedtime. B. Recommend exercise and recreation in the morning. C. Allow the client to select an arts and crafts activity. D. Put the client in charge of choosing snacks for the unit.

Correct Answer is C

Explanation

A. Encouraging daily weigh-ins may exacerbate anxiety and fixation on weight, which is not therapeutic.
B. Exercise and recreation recommendations should align with the treatment plan and be individualized; morning activities are not universally indicated.
C. Allowing the client to select an arts and crafts activity provides a positive outlet for expression and engagement in non-food-related activities.
D. Putting the client in charge of choosing snacks for the unit may not be appropriate, as it could contribute to unhealthy food-related behaviors.

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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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