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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Alprazolam is a benzodiazepine used for anxiety and should not necessarily be discontinued solely based on discontinuation of an antipsychotic.
B. Lithium is a mood stabilizer commonly used in bipolar disorder but is not necessarily discontinued with the discontinuation of an antipsychotic.
C. Benztropine is an anticholinergic medication often used to manage extrapyramidal symptoms (EPS) associated with antipsychotic medications. If the antipsychotic is discontinued,
benztropine may also be discontinued.
D. Magnesium is not typically associated with antipsychotic use, and its discontinuation would depend on the specific indication and circumstances.

A. Shielding the client from direct sunlight when outdoors. B. Gradually withdrawing the medication over several days. C. Enforcing a fluid restriction during dosage adjustment. D. Increasing the dosage if the white blood cell count drops.

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

Explanation

A. Shielding the client from direct sunlight is important because some antipsychotic medications, including haloperidol, can increase sensitivity to sunlight, leading to sunburn.
B. Gradually withdrawing the medication over several days is a prudent approach to avoid withdrawal symptoms and potential worsening of symptoms.
C. Enforcing a fluid restriction is not typically necessary during dosage adjustment for antipsychotic medications like haloperidol.
D. Increasing the dosage if the white blood cell count drops is not a standard practice during the dosage adjustment of antipsychotic medications. Monitoring for adverse effects and adjusting the dosage accordingly is important, but the decision should be based on a comprehensive assessment rather than a single laboratory value.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

Correct Answer is C

Explanation

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

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

Explanation

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