A client with psychosis who is receiving an antipsychotic medication is continually rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Choice A reason: This is not the action that the nurse should implement. Determining Glasgow Coma Scale score is a method of assessing the level of consciousness and neurological function of the client, but it is not a priority intervention in this situation. The client's respiratory rate and oxygen saturation are more critical indicators of the client's condition and the need for immediate action. The nurse should assess the Glasgow Coma Scale score as part of the ongoing evaluation, but it is not the first action.

Choice B reason: This is not the action that the nurse should implement. Initiating cardiopulmonary resuscitation (CPR) is a lifesaving procedure that is performed when the client has no pulse and no breathing, but it is not indicated in this situation. The client has a respiratory rate of 4 breaths/minute, which is very low, but not absent. The client also has an oxygen saturation of 75%, which is very low, but not incompatible with life. The nurse should provide oxygen therapy and ventilatory support to the client, but not CPR.

Choice C reason: This is not the action that the nurse should implement. Preparing to assist with chest tube insertion is a procedure that is done to drain air or fluid from the pleural space and restore lung expansion, but it is not relevant in this situation. The client's respiratory depression is caused by the opioid overdose, not by a pneumothorax or a pleural effusion. The nurse should monitor the client's chest x-ray and lung sounds, but not prepare for chest tube insertion.

Choice D reason: This is the action that the nurse should implement. Administering a second dose of naloxone is the most appropriate and effective intervention in this situation. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression, sedation, and hypotension. However, naloxone has a shorter duration of action than most opioids, and it may require repeated doses to maintain the reversal. The nurse should administer a second dose of naloxone if the client's respiratory rate and oxygen saturation do not improve or worsen after the first dose. The nurse should also monitor the client for signs of opioid withdrawal, such as agitation, nausea, or pain.

Choice A reason: Using the eye drops until the excess pressure is reduced is not an accurate response, as it implies that the eye drops are only a temporary treatment. Open-angle glaucoma is a chronic condition that causes increased pressure in the eye due to impaired drainage of the aqueous humor. The eye drops are used to lower the eye pressure and prevent further damage to the optic nerve. The client will need to use the eye drops for the rest of their life, unless the healthcare provider advises otherwise.

Choice B reason: Using the eye drops for long-term control of pain and swelling is not an accurate response, as it does not address the main goal of the treatment. Open-angle glaucoma does not usually cause pain or swelling, as the pressure builds up gradually and painlessly. The eye drops are used to lower the eye pressure and prevent vision loss, not to relieve inflammation or discomfort.

Choice C reason: Using the eye drops until a smaller angle can be restored is not an accurate response, as it confuses open-angle glaucoma with closed-angle glaucoma. Open-angle glaucoma is characterized by a wide and open angle between the iris and the cornea, which allows the aqueous humor to flow freely. Closed-angle glaucoma is characterized by a narrow or closed angle that blocks the drainage of the aqueous humor. The eye drops are used to lower the eye pressure and prevent further damage to the optic nerve, not to change the angle of the eye.

Choice D reason: Using the eye drops for long-term control of normal eye pressure is the most accurate response, as it reflects the purpose and duration of the treatment. Open-angle glaucoma is a chronic condition that requires lifelong management. The eye drops are used to lower the eye pressure and prevent vision loss, which can occur if the pressure is too high for too long. The client should use the eye drops as prescribed and follow up with the healthcare provider regularly.