How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.
The client has prescriptions for an anxiolytic and an SSRI antidepressant.
Which of the following precautions should the nurse take?.

A.

Restrict interactions with other clients

B.

Document the client's behavior every 2 hr.

C.

Implement 24-hr one-to-one nursing observation.

D.

Administer prescribed medication via the IM route.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.

Choice B rationale:

Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.

Choice C rationale:

Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.

Choice D rationale:

Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. Opioid withdrawal typically results in tachycardia, not bradycardia.

Choice B rationale:

This statement is correct. Diarrhea is a common symptom of opioid withdrawal.

Choice C rationale:

This statement is incorrect. Opioid withdrawal often results in restlessness and agitation, not hypokinesis.

Choice D rationale:

This statement is incorrect. Opioid withdrawal typically results in dilated pupils, not meiosis.

Correct Answer is A

Explanation

Choice A rationale:

Cardiac arrhythmia is a contraindication for electroconvulsive therapy (ECT) because ECT can cause changes in heart rate and blood pressure, which could be dangerous for someone with an existing heart condition.

Choice B rationale:

Crohn’s disease is not a contraindication for ECT. It is a chronic inflammatory bowel disease, and while it can cause significant health problems, it does not directly affect the safety or efficacy of ECT.

Choice C rationale:

Renal colic, a type of pain that can occur when a kidney stone is present, is not a contraindication for ECT. It is unrelated to the brain and nervous system and does not affect the safety or efficacy of ECT.

Choice D rationale:

Asthma is not a contraindication for ECT. While severe asthma should be well-controlled before any procedure that involves anesthesia, it is not a direct contraindication for ECT.

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

Register