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?.
Restrict interactions with other clients
Document the client's behavior every 2 hr.
Implement 24-hr one-to-one nursing observation.
Administer prescribed medication via the IM route.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. It’s important to avoid showing too much emotion, which could be misinterpreted by the client.
Choice B rationale:
Being vague when answering the client’s questions about instructions could increase the client’s paranoia. Clear and direct communication is essential.
Choice C rationale:
Asking the client why he is suspicious of others could lead to defensive behavior. It’s better to focus on building trust and understanding.
Choice D rationale:
Using an overly friendly approach could be perceived as insincere or manipulative by a client with paranoid personality disorder. A neutral demeanor is more effective.
Correct Answer is ["2.5"]
Explanation
The correct answer is 2.5 mL. Calculation: Identify the desired dose: 50 mg Identify the available dose: 20 mg/mL Apply the formula: Desired ÷ Available = Volume to administer Calculation: 50 mg ÷ 20 mg/mL = 2.5 mL
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