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 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.

A. advise the client to take an anxiolytic to decrease their anxiety level. B. restrain the client to prevent self-harm. C. assist the client to identify the trigger situation and choose a coping strategy. D. encourage the client use self-harm behaviors to release emotion.

Correct Answer is C

Explanation

C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.

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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

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Correct Answer is C

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