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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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety.
Choice B rationale
Using light restraints is not recommended due to ethical concerns and potential harm.
Choice C rationale
Administering antianxiety medication should not be the first strategy due to potential side effects and over-medication.
Choice D rationale
Encouraging napping during the day may worsen nighttime wakefulness and wandering.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale: Maintaining a low stimulation environment helps reduce agitation and confusion in clients with delirium. Minimizing noise, light, and activity can create a calming atmosphere, which is essential for clients experiencing sensory overload and cognitive disturbances.
Choice B rationale: Alternating nursing staff daily can disrupt continuity of care, which may increase the client's confusion and anxiety. Familiarity with consistent caregivers helps provide a stable environment, promoting better management of delirium symptoms.
Choice C rationale: Providing the client with limited information about their diagnosis is not helpful. It is important to keep the client informed to the extent they can understand, which helps in reorienting them and reducing confusion about their situation.
Choice D rationale: Approaching the client slowly is crucial in managing agitation and confusion. A calm and non-threatening approach helps in gaining the client's trust, making them feel more secure and reducing the likelihood of aggressive behavior.
Choice E rationale: Reorienting the client to person, place, and time frequently is vital in managing delirium. Regular reorientation helps the client regain a sense of reality and reduces confusion. This intervention is key to improving cognitive function and managing disorientation.
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