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. Neglect occurs when a caregiver fails to provide for a child's basic needs, such as food, shelter, clothing, medical care, education, or emotional support. In this scenario, the child's statement about not eating for days and feeling worried because their parents are away suggests a lack of provision for basic needs, indicating possible neglect.
B. Sexual abuse involves inappropriate sexual behavior or contact imposed upon a child by an adult or older child. There is no indication of sexual abuse in the child's statement about not eating for days and feeling worried because their parents are away.
C. Financial abuse typically involves the misuse or withholding of a child's financial resources by a caregiver. While financial abuse can manifest in various forms, such as stealing a child's money or preventing access to resources, there is no direct mention of financial abuse in the child's statement.
D. Bullying involves repeated aggressive behavior intended to intimidate, harm, or exert control over another individual. There is no indication of bullying in the child's statement to the school nurse.

A. Conduct Disorder B. Autism Spectrum Disorder C. Oppositional Defiant Disorder D. Childhood depression

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.

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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

While talking to the school nurse, a child in third grade states, "My parents are away and I have not eaten for days. I am worried that my parents forgot about me and my little brother." The nurse would suspect what type of abuse?

Correct Answer is A

Explanation

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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