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.

Answer and Explanation

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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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.

A. Have you discussed this with your partner. B. Do you have a friend who could help you. C. Tell me about your baby. D. Have you tried any soothing techniques for your baby.

Correct Answer is C

Explanation

Choice A rationale

Asking about discussing the situation with the partner does not immediately address the priority concern of the baby’s current state.

Choice B rationale

Asking about a friend’s help does not directly address the urgency of the infant's welfare.

Choice C rationale

Asking about the baby’s current condition immediately assesses safety and well-being, which is the nurse’s priority.

Choice D rationale

Inquiring about soothing techniques is not the primary focus in assessing the immediate safety and state of the baby.

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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?

Nursing Test Bank

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Explanation

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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?