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
Referring the client for social services support is important but not the first action in addressing immediate safety.
Choice B rationale
Identifying thoughts of self-harm is crucial for immediate safety and risk management, making it the priority action.
Choice C rationale
Reinforcing coping skills is valuable but secondary to ensuring the client's safety.
Choice D rationale
Encouraging use of personal support systems is helpful but not the first priority in addressing immediate risk. .
Correct Answer is A
Explanation
Choice A rationale
Demonstrating a neutral demeanor helps build trust with a client who has a paranoid personality disorder. This approach is non-threatening and avoids triggering the client's suspicious tendencies.
Choice B rationale
Using an overly friendly approach can increase the client's suspicion and anxiety, making them feel manipulated or deceived.
Choice C rationale
Asking the client why they are suspicious can be perceived as confrontational and may cause the client to become defensive and less cooperative.
Choice D rationale
Being vague when answering the client's questions can increase their paranoia and mistrust, as it may seem like the nurse is hiding something.
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