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 C
Explanation
Choice A rationale:
Psychodrama is a therapeutic approach that uses dramatic role play to help clients gain insight into their feelings and behaviors. However, it may not be the most effective for a client with antisocial personality disorder and alcohol dependency.
Choice B rationale:
Crisis intervention is a short-term therapy to stabilize a client during an acute crisis. It may not address the long-term needs of a client with antisocial personality disorder and alcohol dependency.
Choice C rationale:
Dual diagnosis treatment is designed for clients who have a mental health disorder and a substance use disorder. This would be the most appropriate for a client with antisocial personality disorder and alcohol dependency.
Choice D rationale:
Codependency support groups are typically for family members and friends of individuals with substance use disorders. They may not be the most beneficial for the client themselves.
Correct Answer is A
Explanation
Choice A rationale:
Acknowledging an inability to control drinking is the first step in many recovery models, including the 12-step program of Alcoholics Anonymous. This step involves admitting that alcohol has taken over one’s life.
Choice B rationale:
Agreeing to a prescription for an alcohol use deterrent can be a part of the recovery process, but it is not typically the first step.
Choice C rationale:
Incorporating a form of spirituality into daily life can be a part of the recovery process for some individuals, but it is not typically the first step.
Choice D rationale:
Forming a close support network is crucial in the recovery process, but it comes after acknowledging the problem.
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