The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

Insert a nasogastric tube

Monitor airway and vital signs

Insert an indwelling urinary catheter or monitor output

Anticipate and treat hyperpyrexia with cooling measures

Answer and Explanation

The Correct Answer is B

B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.

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Correct Answer is ["B","C","D"]

Explanation

B. Knowing whether they have sought treatment previously can help in understanding their treatment history, what interventions have been tried, and their level of engagement with treatment services. It can also indicate whether they might benefit from continuing with previous successful interventions or trying new approaches.
C. This information provides crucial information about the client's current alcohol use and potential withdrawal risks. Understanding when the client last consumed alcohol helps in assessing the severity of their alcohol dependence, the potential for withdrawal symptoms, and the urgency of intervention.
D. Understanding the client's coping skills helps in developing a comprehensive treatment plan tailored to their needs. Clients with effective coping skills may have a better prognosis and be more receptive to certain treatment approaches, while those lacking coping skills may require additional support and skill- building interventions.
A. Track marks typically refer to visible signs of intravenous drug use, often associated with substances like heroin. While individuals with alcoholism may have comorbid substance use disorders, track marks specifically indicate a history of intravenous drug use, not alcoholism.

A. Promoting activities that encourage self-reflection B. Identifying community resources C. Providing positive feedback D. Conveying an accepting attitude

Correct Answer is D

Explanation

D. Conveying an accepting attitude involves demonstrating empathy, respect, and non-judgmental acceptance of the client as they are. Clients with BPD often have a fear of rejection and abandonment, so feeling accepted and understood by the nurse is critical for building trust.
A. In the early stages of group intervention, clients may not yet feel comfortable engaging in deep self-reflection without first establishing trust in the nurse and the group.
B. Identifying community resources is important for comprehensive care, but it may not be the most essential aspect initially for establishing trust.
C. Providing positive feedback can help reinforce positive behaviors and build rapport with clients, but it may not be the most essential aspect initially for establishing trust.

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The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

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Naxlex Comprehensive Predictor Exams

When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

Correct Answer is ["B","C","D"]

Explanation

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

Correct Answer is D

Explanation

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