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 D
Explanation
Choice A rationale
Adolescents preparing for college typically have more independence and support systems in place, reducing their risk for physical abuse.
Choice B rationale
Preschoolers' reluctance to share is a common developmental behavior and doesn't significantly elevate their risk for abuse.
Choice C rationale
School-age children wanting to attend summer camp usually have external support and interactions that provide some level of protection.
Choice D rationale
Toddlers with chronic illnesses like cystic fibrosis may be at higher risk for physical abuse due to the increased stress and demands on caregivers. .
Correct Answer is B
Explanation
Choice A rationale
Splitting is a defense mechanism where a person sees things in black-and-white, without the capacity to recognize nuances or integrate good and bad qualities together.
Choice B rationale
Suppression is a conscious decision to delay dealing with stressors or emotions until a later time, as the client does by focusing on their son’s wedding before addressing their health.
Choice C rationale
Reaction formation involves behaving in a way that's opposite to one's true feelings, which does not align with the client's expressed actions.
Choice D rationale
Projection is attributing one's own thoughts, feelings, or impulses to another person, not evident in the client's behavior.
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