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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?.

A.

Restrict interactions with other clients

B.

Document the client's behavior every 2 hr.

C.

Implement 24-hr one-to-one nursing observation.

D.

Administer prescribed medication via the IM route.

Answer and Explanation

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 D

Explanation

Choice A rationale:

This statement is generalizing the client’s feelings, which can lead to a lack of individualized care.

Choice B rationale:

This statement is not acknowledging the client’s feelings of grief, which can lead to a lack of trust in the nurse-client relationship.

Choice C rationale:

This statement is self-disclosing personal information, which can lead to boundary violations in the nurse-client relationship.

Choice D rationale:

This statement is encouraging the client to express their feelings, which can help in the grieving process.

Correct Answer is B

Explanation

Choice A rationale:

Hypomagnesemia is not a common finding in clients with bulimia nervosa.

Choice B rationale:

Hypokalemia is a common finding due to purging behaviors, such as self-induced vomiting or misuse of laxatives, which can lead to loss of potassium.

Choice C rationale:

Muscle wasting is more commonly associated with anorexia nervosa, not bulimia nervosa.

Choice D rationale:

Lanugo, or fine body hair, is also more commonly associated with anorexia nervosa, not bulimia nervosa.

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