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 []
Explanation
Condition Most Likely Experiencing:
Delirium
- The client's acute confusion, restlessness, disorientation, and inability to perform basic tasks suggest delirium rather than dementia or normal aging. Delirium often has an underlying cause, such as infection or medication side effects, and requires immediate intervention.
Actions to Take:
Monitor for an underlying infection.
- Explanation: Infections, particularly urinary tract infections (UTIs) in older adults, are a common cause of delirium. Since the client has been incontinent, an infection could be contributing to the confusion. Identifying and treating the infection can help resolve symptoms.
Use symbols rather than written signs for directions.
- Explanation: Since the client is confused and struggling to recognize basic instructions (e.g., confusing the call light with the TV remote), visual cues like symbols can help them navigate their environment and follow instructions more easily.
Parameters to Monitor:
Presence of agnosia.
- Explanation: Agnosia (difficulty recognizing objects or their use) can indicate cognitive decline. The client mistaking a washcloth for something that belongs in a dryer suggests possible cognitive impairment, and tracking this symptom will help assess changes in mental status.
Ability to complete familiar tasks.
- Explanation: Monitoring whether the client can complete daily activities (e.g., using the call light correctly, self-care) will help determine if their confusion is improving or worsening over time.
Incorrect Choices and Explanations:
Anticipate a prescription for donepezil.
- Why Incorrect? Donepezil is used for Alzheimer’s disease, which develops gradually, unlike delirium, which is sudden and reversible if the cause is treated.
Anticipate a prescription for duloxetine.
- Why Incorrect? Duloxetine is an antidepressant. While depression can cause confusion, this case strongly suggests acute delirium rather than major depressive disorder.
Determine the date of the client’s last eye examination.
- Why Incorrect? Vision problems are not the primary concern in this case. The client's confusion is more likely related to delirium rather than visual impairment.
Night vision.
- Why Incorrect? While vision problems can impact safety, the client’s confusion is the main issue here, not their ability to see at night.
Attendance at group therapy.
- Why Incorrect? Group therapy is useful for conditions like depression or dementia but does not address the immediate, acute nature of delirium.
Oxygen saturation.
- Why Incorrect? The client’s oxygen saturation is already normal (97%), making it an unlikely cause of the delirium. The focus should be on potential infection or other triggers.
Correct Answer is B
Explanation
Choice A rationale:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
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