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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Making a personal introduction to the client at each interaction is a recommended approach for clients with dementia. It helps to orient the client and establish a connection, which can reduce confusion and anxiety.
Choice B rationale:
Giving a client with dementia a list of foods to choose from for dinner may be overwhelming due to impaired decision-making abilities.
Choice C rationale:
Choice D rationale:
Providing a dark environment for sleeping can be disorienting for a client with dementia. A low level of light can help the client maintain orientation to their surroundings.
Correct Answer is B
Explanation
Choice A rationale:
Using restraints can lead to injury and is generally a last resort.
Choice B rationale:
Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
Choice C rationale:
Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
Choice D rationale:
While medication can be helpful, non-pharmacological interventions should be tried first.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.