An 18-year-old 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?

The drug that was ingested.

The time since drug ingestion.

Reason for the suicide attemp

Past history of depression.

Answer and Explanation

The Correct Answer is A

Choice A rationale: A. The drug that was ingested is the most important information because knowing the specific substance determines the course of treatment. For example, acetaminophen overdose requires administration of N-acetylcysteine, while opioid overdose requires naloxone. Different drugs have different toxic effects, antidotes, and supportive measures, making this information critical to providing appropriate and potentially life-saving care.

Choice B rationale: The time since drug ingestion is important because many interventions, such as gastric lavage or activated charcoal, are time-sensitive. However, without knowing the specific drug, it is difficult to determine whether these interventions are necessary or effective

Choice C rationale: Knowing the reason for the suicide attempt is important for overall assessment and treatment planning but may not provide immediate information for the current situation.

Choice D rationale: Past history of depression is relevant to the client's overall mental health, but in the context of a suspected drug overdose, the time since ingestion takes precedence.

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Correct Answer is B

Explanation

A. Referral to a social worker may be beneficial for long-term support and resources. However, it does not address the client’s immediate sense of fear and need for safety.

B. Offering a safe place to relax is the priority because the client is expressing fear and possible threat from a stalker. Ensuring immediate safety and reducing anxiety aligns with the priority principle of protecting the client from harm.

C. Arranging an interview with the healthcare provider is important for further evaluation and planning. However, it does not address the client’s immediate emotional distress and perceived danger.

D. Asking for details about the stalker may be part of assessment, but it should occur after the client feels safe. Gathering information is secondary to ensuring the client’s immediate safety and emotional stabilization.

A. "This medication may cause watery eyes and diarrhea. These will go away within 2 weeks." B. "Side effects are not likely with this type of medication. There should be no need to worry." C. "I can provide an education sheet with your discharge papers. What is your primary language?" D. "This type of medication is generally well tolerated. Tell me more about your concerns."

Correct Answer is D

Explanation

Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.

Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.

Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.

Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.

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An 18-year-old 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

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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