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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Light therapy can be an effective treatment for certain conditions, like seasonal affective disorder, but it typically does not require informed consent unless it's experimental or has significant risks.
Choice B rationale
Experimental medications require informed consent due to the potential unknown effects and risks. Ensuring the client is fully informed about the experimental nature and possible side effects is crucial.
Choice C rationale
Participating in a group exercise program generally does not require informed consent. These activities are typically part of routine care and considered low risk.
Choice D rationale
Attending a cognitive behavioral therapy class usually does not require informed consent beyond the initial agreement to participate in therapy. These sessions are standard parts of mental health care.
Correct Answer is D
Explanation
Choice A rationale
Withdrawn behaviors are not typically associated with antisocial personality disorder, which usually involves more outwardly aggressive and manipulative behaviors.
Choice B rationale
Blunted affect is more commonly associated with conditions like schizophrenia or depressive disorders, rather than antisocial personality disorder.
Choice C rationale
Excessively anxious behavior is more characteristic of anxiety disorders, not antisocial personality disorder, which often involves a lack of anxiety and remorse.
Choice D rationale
Exploitive of others is a key characteristic of antisocial personality disorder, as individuals often disregard the rights of others and manipulate them for personal gain.
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