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.
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Related Questions
Correct Answer is D
Explanation
D. This recognizes that the client's improvement in mood is a typical response to antidepressant medication and does not automatically suggest any negative outcomes such as suicidal ideation or serotonin syndrome.
A. It's important to be vigilant for signs of suicidal ideation but sudden improvements in mood can also occur as a positive response to antidepressant medication.
B. The client's description of feeling better does not align with the symptoms of serotonin syndrome, which include agitation, confusion, rapid heart rate, high blood pressure, and hyperthermia.
C. Antidepressant medications often take several weeks to reach their full therapeutic effect, so it's not unusual for some clients to experience an improvement in mood within the first few weeks of treatment.
Correct Answer is C
Explanation
C. Individuals with BPD often experience intense fears of abandonment and may go to great lengths to avoid being alone. They may also have difficulties being alone due to chronic feelings of emptiness and the need for others to help manage emotions. This characteristic is consistent with the known symptoms of BPD, which include efforts to avoid real or perceived abandonment and a pattern of intense and unstable relationships.
A. Individuals with borderline personality disorder (BPD) often struggle with regulating their emotions, including anger. While they may experience intense emotions such as anger, they typically have difficulty controlling or expressing it in a healthy and adaptive manner.
B. Stable and satisfactory relationships: Stability in relationships is often a challenge for individuals with BPD. They may experience intense and unstable interpersonal relationships characterized by idealization and devaluation of others.
D. Predictability is generally lacking in individuals with BPD due to their emotional instability, impulsivity, and difficulty regulating their behaviors and responses to situations.
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