A nurse is caring for a client who has been admitted with a suspected stimulant overdose. Which of the following nursing priorities should the nurse implement first?
A: Administer activated charcoal to the client.
B: Obtain a urine sample from the client for drug testing.
C: Initiate seizure precautions for the client.
D: Monitor vital signs frequently.
The Correct Answer is D
Choice A Reason:
Administering activated charcoal can be a treatment option in some overdose cases, particularly when the substance ingested is known to be adsorbed by charcoal. However, its effectiveness varies depending on the substance and the timing of administration post-ingestion. In the case of a stimulant overdose, activated charcoal is not the first-line treatment, especially when the specific stimulant and time of ingestion are unknown.
Choice B Reason:
Obtaining a urine sample for drug testing is important for confirming the type of stimulant ingested and can guide further treatment. However, this is not the immediate priority in an acute overdose situation where the patient's life may be at risk.
Choice C Reason:
Initiating seizure precautions is important in the management of stimulant overdose due to the risk of seizures¹. However, this is a precautionary measure and not the first action to take. The initial focus should be on assessing and stabilizing the patient's vital functions.
Choice D Reason:
Monitoring vital signs is the most critical initial step in managing a suspected stimulant overdose. Stimulants can cause severe hypertension, tachycardia, hyperthermia, and arrhythmias. Frequent monitoring allows for the early detection of life-threatening conditions and the initiation of appropriate interventions to stabilize the patient's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
While giving the family an opportunity to talk about their feelings is important, it is not the immediate priority for staff intervention following the incident. The family's needs are crucial, but the question specifically asks about the staff's follow-up actions.
Choice B reason:
Investigating and identifying cues in the client's behavior that might have indicated contemplation of suicide is a critical step in understanding and preventing future incidents. However, this is more of a retrospective action and not the immediate priority for staff intervention after such an event.
Choice C reason:
Providing professional counseling for staff members is the priority intervention. Staff members may experience a range of emotions, including grief, guilt, and trauma, following a client's suicide. Professional counseling can support staff in processing these feelings and prevent potential long-term psychological effects.
Choice D reason:
Changing policies for staff observation of clients who are suicidal may be necessary, but it is not the immediate priority following the incident. Policy review and changes are part of a longer-term strategy to improve care and prevent future incidents.
Correct Answer is C
Explanation
Choice A reason:
Escorting the client to the common area is not the priority action. While being around others can sometimes be comforting, during a panic attack, the client may feel overwhelmed and exposed, which could exacerbate the situation.
Choice B reason:
Contacting security for possible restraints should be a last resort and is not the priority action. Restraints can increase anxiety and fear, potentially escalating the panic attack. The use of restraints is only considered when the client is at risk of harming themselves or others and all other interventions have failed.
Choice C reason:
Staying with the client is the priority action. During a panic attack, the client needs reassurance and a sense of safety. The nurse's presence can provide comfort. The nurse should remain calm, use a quiet voice, and avoid making any sudden movements. Implementing relaxation techniques and promoting a calming environment are also beneficial.
Choice D reason:
Staying away from the client is not the priority action. Leaving the client alone can increase feelings of isolation and fear. The nurse should provide continuous observation and support during the panic attack.
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