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 A

Explanation

A. Conduct Disorder is characterized by a repetitive and persistent pattern of behavior that violates the rights of others or major age-appropriate societal norms or rules. It often includes aggressive behavior towards people or animals, destruction of property, deceitfulness or theft, and serious violations of rules.
B. Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by difficulties in social interaction and communication, as well as restricted and repetitive patterns of behavior, interests, or activities.
C. Oppositional behavior is present in ODD but the severity and nature of the behaviors described in the scenario (prostitution, running away, and abuse towards parents) are more consistent with Conduct Disorder rather than ODD.
D. Childhood depression, also known as pediatric depressive disorder, involves persistent feelings of sadness, hopelessness, or irritability that interfere with daily functioning.

A. Orient the client and offer reassurance B. Encourage the client to drink some fluids C. Orient the client and monitor vital signs D. Assist the client from the stretcher to a wheelchair

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.

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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

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client's parents reported that they have run away several times and is abusive towards them. The nurse should anticipate that the diagnosis will be:

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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