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 B
Explanation
Choice A rationale:
While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
Choice B rationale:
This response is the priority as it assesses the immediate safety of the baby.
Choice C rationale:
While support is important, the immediate safety of the baby is the priority.
Choice D rationale:
While communication with the partner is important, the immediate safety of the baby is the priority.
Correct Answer is B
Explanation
Choice A rationale:
Attending a cognitive behavioral therapy class does not require informed consent as it is a non-invasive form of treatment.
Choice B rationale:
Informed consent is necessary when taking an experimental medication to ensure the client understands the potential risks and benefits.
Choice C rationale:
Light therapy is a non-invasive treatment and does not typically require informed consent.
Choice D rationale:
Participating in a group exercise program is a non-invasive form of treatment and does not require informed consent.
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