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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Excessive anxiety is not typically associated with antisocial personality disorder. It is more commonly seen in anxiety disorders.
Choice B rationale:
Withdrawn behaviors are more commonly associated with disorders such as depression or social anxiety disorder, not antisocial personality disorder.
Choice C rationale:
Exploiting others is a common characteristic of antisocial personality disorder. Individuals with this disorder often manipulate or deceive others for personal gain.
Choice D rationale:
Blunted affect, or reduced emotional expression, is not typically associated with antisocial personality disorder. It is more commonly seen in disorders such as schizophrenia.
Correct Answer is B
Explanation
Choice A rationale:
A motor-vehicle crash is an adventitious crisis, not a maturational one.
Choice B rationale:
A child leaving for college is a normal developmental milestone that can cause stress.
Choice C rationale:
Loss of a job is a situational crisis, not a maturational one.
Choice D rationale:
Divorce is a situational crisis, not a maturational one.
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