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.

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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Correct Answer is C

Explanation

Choice A rationale:

Encouraging the client to attend a daily exercise program on the unit is beneficial for the client’s health, but it does not demonstrate the ethical principle of veracity, which involves truthfulness and honesty.

Choice B rationale:

Maintaining the client’s confidentiality about a substance use disorder is an important aspect of nursing care, but it demonstrates the ethical principle of confidentiality, not veracity.

Choice C rationale:

Reinforcing information on the potential adverse effects of a medication with the client is an example of veracity. The nurse is being truthful and transparent about the potential risks associated with the medication.

Choice D rationale:

Respecting the client’s right to refuse to attend a group therapy session demonstrates the ethical principle of autonomy, not veracity.

A. Encourage the client to visit with the sibling. B. Tell the sibling the client does not want visitors. C. Arrange for the sibling to visit the client in the dayroom. D. Refer the sibling to the client's provider.

Correct Answer is B

Explanation

Choice A rationale:

It’s not appropriate to pressure the client into seeing visitors.

Choice B rationale:

It’s important to respect the client’s wishes and communicate them to the sibling.

Choice C rationale:

This could potentially cause distress for the client.

Choice D rationale:

While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?.

Correct Answer is C

Explanation

A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?.

Correct Answer is B

Explanation

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?.

A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?.

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A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?.

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care? .

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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?.