A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

Reason for the suicide attempt.

The drug that was ingested.

The time since drug ingestion.

Past history of depression.

Answer and Explanation

The Correct Answer is B

A) While understanding the reason for the suicide attempt can provide important context, it is not as critical in the immediate management of a suspected overdose as knowing the specifics of what was ingested.

B) Identifying the drug that was ingested is the most important information for the nurse to obtain. Knowing the specific substance allows for appropriate and timely treatment, including the administration of antidotes if applicable and understanding potential complications.

C) The time since drug ingestion is also relevant, as it can influence treatment decisions and urgency. However, without knowing the specific drug, it may be challenging to determine the best course of action.

D) A past history of depression is important for the overall understanding of the client's mental health, but it does not have immediate implications for managing an overdose. The priority is to address the acute medical situation first.

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Correct Answer is D

Explanation

A) Praising the client for her new behavior can be encouraging and may boost her self-esteem. However, it’s essential to approach this cautiously, as excessive praise might overwhelm her or be perceived as insincere. While positive reinforcement is valuable, it should not be the sole focus of the intervention.

B) Offering her a choice of activities can promote autonomy and encourage engagement, but given her recent shift from despondency to exhibiting energy, it’s crucial to assess her mood and mental state carefully first. Providing choices may be helpful, but it should be accompanied by vigilant monitoring to ensure her safety.

C) Involving her in group therapy could facilitate social interaction and support, but it may not be appropriate immediately. After several days of nonverbal behavior, she may still be vulnerable. Group settings could be overwhelming, and her readiness to participate should be carefully evaluated.

D) Observing her actions continuously is the most critical action at this stage. The change in her behavior—from being despondent and nonverbal to talking and exhibiting energy—can indicate a potential shift toward increased risk for impulsivity or self-harm. Continuous observation allows the nurse to assess her safety and intervene if her behavior escalates, ensuring she is supported during this transitional phase.

A. Listen to what the client is saying B. Sit in the chair next to the client. C. Escort the client to his room. D. Administer a PRN sedative.

Correct Answer is C

Explanation

A) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.

B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.

C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.

D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.

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A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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