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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Correct Answer is C
Explanation
C. After ECT, the client may be disoriented, confused, or drowsy due to the effects of anesthesia and the procedure itself. Orienting the client to their surroundings and situation helps promote their safety and comfort. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is crucial to assess the client's immediate post-procedural status and detect any complications.
A. Offering reassurance can help alleviate any anxiety or confusion the client may experience. However, while this intervention is important, it may not be the first priority immediately upon admission to the Post Anesthesia Care Unit (PACU).
B. Hydration is important after any medical procedure, including ECT. However, immediately after ECT, the client may still be recovering from anesthesia and may not be fully alert or able to safely drink fluids.
D. Assisting the client with mobility is important but it may not be the first intervention performed in the PACU after ECT. The priority immediately upon admission to the PACU is to ensure the client's safety.
Correct Answer is D
Explanation
D. Acupuncture is based on the concept of Qi (pronounced "chee"), or vital energy, flowing along specific pathways or meridians in the body. The insertion of needles at specific points along these meridians is believed to regulate the flow of Qi, restoring balance and promoting healing.
A. Acupuncture primarily involves the insertion of thin needles into specific points on the body to stimulate nerve-rich areas, not the manipulation of the spinal column.
B. Acupuncture does not involve the ingestion of substances, but rather the insertion of needles into specific points on the body to stimulate energy flow.
C. Herbal remedies may be used in conjunction with acupuncture in traditional Chinese medicine but acupuncture itself does not involve the ingestion of substances.
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