The nurse in the Emergency Department (ED) assesses a 17-year-old client exhibiting symptoms of opiate intoxication. Which of the following should be the nurse's priority action?
Open the crash cart.
Administer oxygen via nonrebreather.
Administer naloxone.
Contact the parents.
The Correct Answer is C
C. Administering naloxone is often the priority action for a client exhibiting symptoms of opiate intoxication, especially if they are experiencing significant respiratory depression or unconsciousness. Naloxone is a medication used to rapidly reverse the effects of opioids, including respiratory depression and sedation.
A. Opening the crash cart is not the priority action for a client exhibiting symptoms of opiate intoxication unless the client's condition deteriorates rapidly, leading to a life-threatening emergency such as respiratory depression or cardiac arrest.
B. This intervention is important for clients experiencing respiratory depression, hypoxemia, or altered mental status due to opiate overdose. However, it may not be the highest priority action if the client's respiratory status is stable
D. Contacting the client's parents or guardians is important for obtaining medical history, consent for treatment (if applicable), and support. However, it may not be the highest priority action in the immediate management of opiate intoxication.
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Related Questions
Correct Answer is B
Explanation
B. The honeymoon phase occurs after the acute battering incident and is characterized by the abuser showing remorse, apologizing, and trying to reconcile with the victim. During this phase, the abuser may express love, affection, and promises to change.
A. This phase is not typically recognized as a distinct phase in the cycle of abuse.
C. The acute battering incident is the phase characterized by the actual physical or emotional abuse. It is the culmination of tension that has been building in the relationship, leading to an explosive and violent incident.
D. The tension-building phase is the initial phase in the cycle of abuse, characterized by increasing tension and conflict between the partners. During this phase, the victim may try to placate the abuser, avoid conflict, or walk on eggshells to prevent escalation.
Correct Answer is C
Explanation
C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.
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