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.

Answer and Explanation

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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Correct Answer is B

Explanation

B. Clients taking disulfiram should avoid all forms of alcohol, including alcoholic beverages such as beer, wine, and spirits. Consuming alcohol while taking disulfiram can lead to a severe and potentially life-threatening reaction known as the disulfiram-alcohol reaction.
A. Anchovies are not specifically contraindicated with disulfiram.
C. Grapefruit juice is not typically contraindicated with disulfiram.
D. Spinach is not specifically contraindicated with disulfiram. There is no known interaction between disulfiram and spinach.

A. Promoting activities that encourage self-reflection B. Identifying community resources C. Providing positive feedback D. Conveying an accepting attitude

Correct Answer is D

Explanation

D. Conveying an accepting attitude involves demonstrating empathy, respect, and non-judgmental acceptance of the client as they are. Clients with BPD often have a fear of rejection and abandonment, so feeling accepted and understood by the nurse is critical for building trust.
A. In the early stages of group intervention, clients may not yet feel comfortable engaging in deep self-reflection without first establishing trust in the nurse and the group.
B. Identifying community resources is important for comprehensive care, but it may not be the most essential aspect initially for establishing trust.
C. Providing positive feedback can help reinforce positive behaviors and build rapport with clients, but it may not be the most essential aspect initially for establishing trust.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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