A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?
Initiate vomiting and apply an enema.
Check pupil size and reflexes.
Establish a patent airway.
Administer IV fluids fast.
The Correct Answer is C
Choice A rationale: Initiating vomiting and applying an enema is not the first action to take when finding an unconscious person. This could potentially cause more harm, especially if the person is unconscious as they could choke. It’s also important to note that inducing vomiting is not a recommended procedure for drug overdoses as it can lead to aspiration, which can cause more harm.
Choice B rationale: Checking pupil size and reflexes is important in assessing a patient’s neurological status. However, it is not the first action to take. The first action should always be to ensure the patient has a patent airway to allow for adequate oxygenation.
Choice C rationale: Establishing a patent airway is the correct first action when finding an unconscious person. This is because maintaining a patent airway is crucial for oxygenation and ventilation. Without a patent airway, the person could suffer from hypoxia, which could lead to brain damage or death.
Choice D rationale: Administering IV fluids fast is not the first action to take when finding an unconscious person. While IV fluids may be necessary later on in the management of the patient, the first action should always be to ensure the patient has a patent airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Identifying triggers for anxiety reactions is a crucial part of managing chronic anxiety. By recognizing what situations, thoughts, or feelings provoke anxiety, the client can begin to develop coping strategies to handle these triggers effectively. This approach is often used in cognitive-behavioral therapy, which is a common treatment for anxiety disorders.
Choice B rationale: While contacting a crisis counselor can be helpful in acute situations, it may not be necessary for a client with chronic anxiety to do so on a weekly basis. Regular therapy sessions with a mental health professional would likely be more beneficial, as they can provide ongoing support and help the client develop long-term coping strategies.
Choice C rationale: It’s unrealistic and unfeasible to completely eliminate stress and anxiety from daily life. Stress is a normal part of life, and everyone experiences it to some degree. Instead, the focus should be on managing stress and anxiety effectively through techniques such as relaxation exercises, mindfulness, and cognitive-behavioral strategies.
Choice D rationale: Trying to repress feelings of anxiety can actually exacerbate them. It’s important for individuals with anxiety disorders to acknowledge their feelings and learn how to manage them, rather than trying to suppress them. Repression can lead to increased anxiety and other mental health issues over time.
Correct Answer is B
Explanation
Choice A rationale:
This response is dismissive of the client's concerns and does not acknowledge their feelings. It also implies that the client is not knowledgeable about their own condition. This could make the client feel defensive and less likely to share their concerns in the future.
It focuses on the medical facts of the diagnosis rather than addressing the client's emotional state. It may come across as patronizing or judgmental, further alienating the client.
Choice B rationale:
This response demonstrates active listening and empathy. It acknowledges the client's feelings and validates their concerns. This can help to build trust and rapport with the client.
It encourages the client to express their fears and worries, which can be therapeutic in itself.
It opens the door for further discussion about the client's concerns and provides an opportunity for the nurse to offer support and education.
Choice C rationale:
This response is reassuring, but it does not address the client's underlying concerns. It may also come across as dismissive or patronizing.
It relies solely on the medical chart to make a judgment about the client's concerns, without taking into account the client's own perspective.
It does not provide an opportunity for the client to express their fears and worries.
Choice D rationale:
This response is a deflection and does not provide the client with the support they need in the moment. It may also make the client feel like their concerns are not being taken seriously.
It shifts the responsibility for addressing the client's concerns to the provider, which may not be helpful if the client is already feeling anxious or uncertain.
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