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 D
Explanation
Choice A rationale:
Alcohol can interfere with sleep patterns and should not be used as a sleep aid.
Choice B rationale:
Napping can make it harder to fall asleep at night.
Choice C rationale:
Eating just before bedtime can cause discomfort and disrupt sleep.
Choice D rationale:
Limiting caffeine intake can help improve sleep, as caffeine is a stimulant that can interfere with the ability to fall asleep.
Correct Answer is D
Explanation
Choice A rationale:
Checking blood pressure once a week is a good practice, especially for clients on medications that can affect blood pressure.
Choice B rationale:
Chewing sugar-free gum several times daily is not harmful and can help with dry mouth, a common side effect of haloperidol.
Choice C rationale:
Avoiding alcohol while taking haloperidol is recommended as alcohol can increase the side effects of the medication.
Choice D rationale:
Spending several hours a day outside gardening when it’s sunny can lead to a condition called photosensitivity, a side effect of haloperidol. The client should be advised to wear protective clothing and sunscreen when outside.
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.