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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.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:

Absence of seizures is not an expected outcome of fluoxetine therapy. Fluoxetine is an antidepressant, not an anticonvulsant.

Choice B rationale:

Reduction in hand tremors is not an expected outcome of fluoxetine therapy. Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks.

Choice C rationale:

Decreased hallucinations is not an expected outcome of fluoxetine therapy. Fluoxetine is not typically used to treat conditions that cause hallucinations.

Choice D rationale:

Improved mood is an expected outcome of fluoxetine therapy. As an antidepressant, fluoxetine works by balancing chemicals in the brain that affect mood and emotions.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.

Choice B rationale:

Being currently married is generally considered a protective factor against suicide, not a risk factor.

Choice C rationale:

Access to lethal means, such as guns in the home, is a significant risk factor for suicide.

Choice D rationale:

A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.

Choice E rationale:

Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.

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