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. The client's statements about having an IQ of 400+, being married to a movie star, and suspecting his brother's intentions may indicate a distorted perception of reality, suggesting disturbed sensory perception. This priority addresses the potential psychosis and immediate safety concerns.
B. Compromised family coping, while important, is a secondary consideration. Addressing the client's altered sensory perception takes precedence to ensure their safety and
stabilization.
C. Ineffective sexual patterns are not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.
D. Impaired environmental interpretation is not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.

A. Help the client identify thoughts that may be triggers. B. Explore past behaviors that have provided relief. C. Attempt to distract to another focus or activity. D. Speak calmly to the client stating assurance of safety.

Correct Answer is D

Explanation

A. Identifying triggers may be beneficial, but the client is currently in a state of severe anxiety, and immediate intervention to address the symptoms is needed.
B. Exploring past behaviors can be addressed later; the immediate focus should be on managing the acute symptoms of anxiety.
C. Attempting to distract the client can be helpful, but providing reassurance and addressing safety concerns take precedence.
D. Speaking calmly to the client and providing assurance of safety is an appropriate first step in managing severe anxiety. Once the client is more settled, other interventions can be explored.

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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

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is A

Explanation

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Correct Answer is D

Explanation

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?

Which individual should the nurse consider at the highest risk for suicide?

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?