Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
Determine the client’s reason for attempting suicide.
Obtain the client’s serum hydrocodone/acetaminophen level.
Encourage the client to increase fluid intake.
Observe the client for further narcotic effects.
The Correct Answer is D
A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.
B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.
C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.
D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.
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Related Questions
Correct Answer is D
Explanation
A. Telling the client to call Adult Protective Services is a valid intervention, but immediate safety planning is crucial.
B. Verifying the client's report by determining physical evidence is important but may not be the most immediate and practical intervention.
C. Referring the client to a program for victims of domestic violence is a valuable option, but immediate safety planning should take precedence.
D. Assisting the client in developing an emergency safety plan is the most important intervention to ensure the client's safety in the present situation.
Correct Answer is D
Explanation
A. Regression involves reverting to an earlier stage of development in response to stress, which is not evident in the client's response.
B. Projection involves attributing one's thoughts or feelings to another person, which is not evident in the client's response.
C. Denial involves refusing to acknowledge the existence of something unpleasant, which is not evident in the client's response.
D. Repression involves unconsciously blocking out memories or feelings, and the client's statement of not remembering past sexual abuse may indicate the use of repression as a defense mechanism.
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