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
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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Related Questions
Correct Answer is D
Explanation
D. This statement prioritizes the client's immediate emotional needs by providing reassurance, validation, and a sense of safety in a traumatic situation. It acknowledges the client's distress and communicates empathy and support, which are essential for building trust and rapport and facilitating the client's emotional healing process.
A. The client may feel overwhelmed by the prospect of speaking to the police at that moment, and it may not be the most therapeutic statement to prioritize.
B. Contacting the client's spouse may provide emotional support and assistance, but it may not be the priority therapeutic statement in this situation.
C. The client may already be feeling vulnerable and exposed, and discussing the need for photographs may exacerbate feelings of distress or discomfort.
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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