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 ["B","D"]
Explanation
Choice A reason:
This statement is incorrect. Nausea, vomiting, and diarrhea can be side effects of lithium and are concerns while on this medication. It is important for clients to report these symptoms to their healthcare provider, as they can be signs of lithium toxicity.
Choice B reason:
This statement is correct. Maintaining adequate sodium intake is important while taking lithium. Sodium levels can affect lithium levels in the body, and sudden changes in sodium intake can lead to lithium toxicity or decreased effectiveness of the medication.
Choice C reason:
This statement is incorrect. Lithium does not necessarily need to be taken on an empty stomach. It can be taken with or without food, although taking it with food may help reduce stomach upset.
Choice D reason:
This statement is correct. Regular monitoring of blood levels is essential during the first month of lithium therapy to ensure that lithium levels are within the therapeutic range and to avoid toxicity. The frequency of monitoring may change based on the results and as treatment continues.
Correct Answer is ["A","B","E"]
Explanation
Choice A reason:
A necklace can pose a risk for clients with suicidal tendencies as it can be used to inflict self-harm. In an acute mental health unit, it is crucial to remove any items that could potentially be used in another suicide attempt. The nurse should ensure that the environment is safe and free from objects that could be used for hanging or strangulation.
Choice B reason:
Lace-up tennis shoes have laces that can be removed and used by the client to harm themselves. It is a standard safety precaution in mental health units to remove any items with strings or laces, such as belts, drawstrings, or shoe laces, to prevent their use in self-harm or suicide attempts.
Choice C reason:
Nylon ankle socks are generally considered safe and do not typically need to be removed. They do not pose a significant risk for self-harm. Therefore, the client can keep these for personal comfort and hygiene.
Choice D reason:
Cotton underwear is a basic necessity and does not present a risk for self-harm. It is important for the client's dignity and hygiene to have access to personal undergarments while in the mental health unit.
Choice E reason:
A glass-framed picture, while sentimental, poses a risk due to the glass, which can be broken and used to inflict self-harm. For safety reasons, any items made of glass or other breakable materials should be removed from the client's access in a mental health unit.
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