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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This approach involves establishing clear and consistent rules and boundaries, which are crucial for managing antisocial behaviors. It helps to create a structured environment where the consequences of actions are predictable and reinforces the understanding of acceptable behaviors.
A. Encouraging the client to explore and address underlying emotions, including feelings of fear and inferiority, can be an important aspect of therapy and may help mitigate manipulative behaviors over time.
B. Antisocial personality disorder is associated with behaviors that violate social norms and the rights of others. Positive reinforcement for these behaviors would not address the underlying issues and may inadvertently reinforce harmful patterns of behavior.
D. Ignoring inappropriate behavior may reinforce the notion that manipulation is an effective means of achieving desired outcomes and may lead to further boundary violations.
Correct Answer is C
Explanation
C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.
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