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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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.
Choice B rationale:
Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.
Choice C rationale:
Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.
Choice D rationale:
Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.
Correct Answer is D
Explanation
Choice A rationale:
Absence of seizures is not an expected outcome of fluoxetine therapy. Fluoxetine is an antidepressant, not an anticonvulsant.
Choice B rationale:
Reduction in hand tremors is not an expected outcome of fluoxetine therapy. Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks.
Choice C rationale:
Decreased hallucinations is not an expected outcome of fluoxetine therapy. Fluoxetine is not typically used to treat conditions that cause hallucinations.
Choice D rationale:
Improved mood is an expected outcome of fluoxetine therapy. As an antidepressant, fluoxetine works by balancing chemicals in the brain that affect mood and emotions.
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