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.

Answer and Explanation

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.

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Correct Answer is ["A","E"]

Explanation

The correct answer is choiceAandE.

Choice A rationale:

Monitoring the client’s weight daily is crucial in managing anorexia nervosa.It helps track the client’s progress and ensures that any significant weight changes are promptly addressed.

Choice B rationale:

Allowing the client to choose their meals can be counterproductive.Clients with anorexia nervosa may make choices that do not support their nutritional needs, potentially exacerbating their condition.

Choice C rationale:

Allowing the client to practice strenuous exercises is not advisable.Strenuous exercise can further deplete the client’s already low energy reserves and exacerbate malnutrition.

Choice D rationale:

Staying with the client during meals and for 2 hours after meals is incorrect.The recommended practice is to stay with the client for 30 minutes after meals to monitor for any purging behaviors.

Choice E rationale:

Providing the client with small meals frequently is beneficial. It helps in managing their nutritional intake without overwhelming them, which can be more acceptable and manageable for clients with anorexia nervosa.

A. Heart rate B. Respiratory rate C. Blood pressure D. Temperature.

Correct Answer is C

Explanation

Choice A rationale: While a heart rate of 52/min is lower than the normal range (60-100/min), it’s not uncommon in individuals with anorexia nervosa due to the body’s adaptation to conserve energy.

However, it’s not the most critical vital sign to address first in this scenario.

Choice B rationale: A respiratory rate of 26/min is slightly elevated (normal range is 12-20/min), possibly due to anxiety or distress.

However, it’s not the most immediate concern compared to other vital signs.

Choice C rationale: The client’s blood pressure is 84/50 mm Hg, which is significantly lower than the normal range (90/60 to 120/80 mm Hg). This could indicate hypotension, which can lead to dizziness, fainting, and inadequate blood flow to organs.

Hypotension is a common complication of anorexia nervosa due to decreased blood volume and weakened heart muscle.

Therefore, it should be addressed first.

Choice D rationale: The client’s temperature is 36.1°C (97°F), which is slightly lower than the normal body temperature range (36.5–37.5°C or 97.7–99.5°F). Hypothermia is a common complication in individuals with anorexia nervosa due to loss of body fat, which provides insulation.

However, it’s not the most immediate concern in this scenario.

In conclusion, the nurse should first address the client’s blood pressure due to the potential risks associated with hypotension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mental health nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 16.7. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse in a mental health unit is admitting a female client who has anorexia nervosa. The admission vital signs are as follows: Heart rate 52/min, Respiratory rate 26/min, Blood pressure 84/50 mm Hg, Temperature 36.1C(97F). The nurse should first address the client's:

Correct Answer is C

Explanation

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