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

Explanation

B. Children who are raised by multiple caregivers may experience challenges in forming secure attachments, receiving consistent discipline and support, and maintaining stability in their environment. These disruptions can contribute to emotional insecurity, behavioral problems, and difficulties in social relationships, which are risk factors for the development of psychiatric disorders.
A. Marital harmony in the household is generally considered a protective factor rather than a predisposing factor for the development of psychiatric disorders in children.
C. Regular prenatal care for the mother is generally considered a protective factor for the child's development rather than a predisposing factor for psychiatric disorders.
D. Achieving developmental milestones on schedule indicates healthy neurological and cognitive development, as well as appropriate social and emotional functioning.

A. Assess for past history of suicide attempts. B. Determine whether the client has a specific plan to commit suicide. C. Identify coping mechanisms. D. Notify all members of the treatment team and place the client on suicide precautions.

Correct Answer is D

Explanation

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which predisposing factor obtained during the nursing assessment would cause the nurse to consider a child to be at risk for the development of a psychiatric disorder?

Correct Answer is B

Explanation

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Correct Answer is D

Explanation

A woman in a severely abusive relationship is hospitalized with severe injuries and head trauma. Her husband sends flowers to the unit and a card begging for forgiveness. The nurse recognizes this to be which phase in an abusive relationship?

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