The nurse in the Emergency Department (ED) assesses a 17-year-old client exhibiting symptoms of opiate intoxication. Which of the following should be the nurse's priority action?
Open the crash cart.
Administer oxygen via nonrebreather.
Administer naloxone.
Contact the parents.
The Correct Answer is C
C. Administering naloxone is often the priority action for a client exhibiting symptoms of opiate intoxication, especially if they are experiencing significant respiratory depression or unconsciousness. Naloxone is a medication used to rapidly reverse the effects of opioids, including respiratory depression and sedation.
A. Opening the crash cart is not the priority action for a client exhibiting symptoms of opiate intoxication unless the client's condition deteriorates rapidly, leading to a life-threatening emergency such as respiratory depression or cardiac arrest.
B. This intervention is important for clients experiencing respiratory depression, hypoxemia, or altered mental status due to opiate overdose. However, it may not be the highest priority action if the client's respiratory status is stable
D. Contacting the client's parents or guardians is important for obtaining medical history, consent for treatment (if applicable), and support. However, it may not be the highest priority action in the immediate management of opiate intoxication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. he CAGE questionnaire is a widely used screening tool for alcohol use disorder (AUD). It consists of four questions that assess the client's alcohol consumption, attempts to cut down or control drinking, feelings of guilt about drinking, and whether alcohol use interferes with daily activities or responsibilities.
B. The CIWA is a tool used to assess the severity of alcohol withdrawal symptoms in individuals with alcohol dependence who are undergoing detoxification or withdrawal management. The CIWA is not specifically used for screening alcohol use disorder but rather for monitoring and managing alcohol withdrawal symptoms in individuals with known alcohol dependence.
C. The AIMS is a tool used to assess for the presence and severity of abnormal involuntary movements, particularly those associated with antipsychotic medications or conditions such as tardive dyskinesia. It is not used for screening alcohol use disorder.
D. The ORT-OUD is a screening tool specifically designed to assess the risk of opioid use disorder (OUD) in individuals who are prescribed opioid medications for chronic pain. It is not used for screening alcohol use disorder.
Correct Answer is B
Explanation
B. Given the client's confusion and the daughter's behavior of constantly interrupting and not allowing the client to answer, there may be concerns about elder abuse or neglect. It's essential to create a safe and private environment for the client to speak freely without interference.
A. The client's confusion and reluctance to speak may raise concerns about their mental status. However, requesting a psychiatric evaluation is not the priority in this scenario. The client's immediate needs, including hydration, nutrition, and safety, should be addressed first.
C. Addressing malnutrition is important but providing nutritional counseling is not the priority in this scenario. The client's severe dehydration and potential abuse or neglect take precedence over nutritional concerns.
D. Obtaining information from the daughter may be helpful but it should not be the sole source of information, especially if there are concerns about the daughter's behavior and potential interference with the client's ability to communicate.
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