A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.
The client has prescriptions for an anxiolytic and an SSRI antidepressant.
Which of the following precautions should the nurse take?.
Restrict interactions with other clients
Document the client's behavior every 2 hr.
Implement 24-hr one-to-one nursing observation.
Administer prescribed medication via the IM route.
The Correct Answer is C
Choice A rationale:
Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.
Choice B rationale:
Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.
Choice C rationale:
Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.
Choice D rationale:
Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Discussing a client’s information with staff who have provided care in the past is not appropriate unless it is necessary for the client’s current care.
Choice B rationale:
The provider does not need to give consent to discuss health information with the client’s family. The client is the one who must give consent.
Choice C rationale:
This statement is correct. A client retains the legal right to privacy of health information even after they have died.
Choice D rationale:
A provider may not speak to a client’s employer regarding a substance use disorder without the client’s consent.
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. People with bulimia nervosa often consume large amounts of food in a short period of time, known as binge eating.
Choice B rationale:
This statement is correct. Despite the binge-purge cycle, individuals with bulimia nervosa can maintain an average or ideal body weight, making the disorder less noticeable.
Choice C rationale:
This statement is incorrect. While self-induced vomiting is a common method of purging in bulimia nervosa, other methods such as excessive exercise, fasting, or misuse of laxatives, diuretics, or enemas can also be used.
Choice D rationale:
This statement is incorrect. While bulimia nervosa can lead to various health complications, it is not directly associated with the development of diabetes mellitus.
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