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:
A school-age child wanting to go to summer camp is not at a higher risk for physical abuse.
Choice B rationale:
A toddler with cystic fibrosis is at a higher risk for physical abuse due to the stress and demands of caring for a child with a chronic illness.
Choice C rationale:
An adolescent preparing to leave home for college is not at a higher risk for physical abuse.
Choice D rationale:
A preschooler who is reluctant to share is not at a higher risk for physical abuse.
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.
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