A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.
The client has prescriptions for an anxiolytic and an SSRI antidepressant.
Which of the following precautions should the nurse take?
Implement 24-hr one-to-one nursing observation.
Document the client's behavior every 2 hr.
Restrict interactions with other clients.
Administer prescribed medication via the IM route.
The Correct Answer is A
Choice A rationale
Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm.
Choice B rationale
Documenting the client's behavior every 2 hr is not sufficient to ensure their safety in an overdose situation.
Choice C rationale
Restricting interactions with other clients does not directly address the immediate risk of harm to the client.
Choice D rationale
Administering prescribed medication via the IM route does not provide the necessary supervision for a client at high risk of self-harm.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Being currently married is generally considered a protective factor against suicide, as supportive relationships can provide emotional stability and reduce the risk of suicidal behavior.
Choice B rationale
Access to guns in the home is a significant risk factor for suicide, as it increases the likelihood of a person using a firearm to attempt suicide, resulting in higher lethality.
Choice C rationale
Having terminal liver cancer is a risk factor for suicide due to the emotional and physical distress associated with a terminal illness, including pain, loss of autonomy, and fear of suffering.
Choice D rationale
Alcohol use disorder is a risk factor for suicide because substance abuse can exacerbate mental health issues, impair judgment, and increase impulsivity, leading to a higher risk of suicidal behavior.
Correct Answer is D
Explanation
Choice A rationale
The PSDA is applicable to all adults, not just those who reach 65 years of age. It ensures patients can make their own health care decisions regardless of age.
Choice B rationale
Advance directives must be documented in writing. A verbal designation of a durable power of attorney is not legally sufficient.
Choice C rationale
Advance directives are applicable to all clients, including those receiving mental health care. They ensure a client’s treatment preferences are respected.
Choice D rationale
A witness is legally required to sign a client's living will to validate the document and ensure that it is the client's voluntary and informed decision.
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