The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?

Get the defibrillator to the patient’s bedside and open the crash cart.

Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.

Administer naloxone intranasally if there is not an IV catheter in place.

Contact the patient’s parents or legal guardian for consent to treat.

Answer and Explanation

The Correct Answer is B

The correct answer is b. Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.

Choice A Reason: Get the defibrillator to the patient’s bedside and open the crash cart

While having the defibrillator and crash cart ready is important in emergency situations, it is not the immediate priority in this scenario. The patient’s symptoms suggest opioid overdose, which requires immediate intervention to support breathing and reverse the effects of the opioid. The primary focus should be on ensuring adequate oxygenation and administering naloxone.

Choice B Reason: Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone

This is the correct answer. The patient’s blue-tinged lips, slowed respirations, and pinpoint pupils are indicative of opioid overdose. Administering oxygen via a 100% nonrebreather mask helps to ensure adequate oxygenation, while placing an IV catheter allows for the administration of naloxone, an opioid antagonist that can reverse the effects of the overdose. This intervention addresses the immediate life-threatening condition.

Choice C Reason: Administer naloxone intranasally if there is not an IV catheter in place

While administering naloxone intranasally is an appropriate alternative if IV access is not available, it is not the first priority. The initial focus should be on ensuring adequate oxygenation and establishing IV access for more effective administration of naloxone. If IV access cannot be quickly established, then intranasal naloxone can be used.

Choice D Reason: Contact the patient’s parents or legal guardian for consent to treat

Obtaining consent is important, but it is not the immediate priority in a life-threatening situation. The nurse’s primary responsibility is to stabilize the patient and address the acute medical emergency. Once the patient is stabilized, the nurse can then contact the parents or legal guardian for further consent and information.

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Correct Answer is B

Explanation

Choice A Reason:

Promoting activities that encourage self-reflection. While promoting self-reflection is important in the therapeutic process, it is not the most essential aspect initially for establishing a trusting nurse-patient relationship. Self-reflection activities are more effective once a foundation of trust has been established.

Choice B Reason:

Conveying an accepting attitude. This statement is correct. Conveying an accepting attitude is crucial in the initial stages of establishing a trusting nurse-patient relationship. Patients with borderline personality disorder often feel judged and misunderstood. An accepting attitude helps to create a safe and supportive environment, which is essential for building trust and encouraging open communication.

Choice C Reason:

Identifying community resources. Identifying community resources is important for long-term support and management of borderline personality disorder, but it is not the most essential aspect initially for establishing trust. This step is more relevant once the therapeutic relationship has been established and the patient is ready to engage with external support systems.

Choice D Reason:

Providing positive feedback. Providing positive feedback is beneficial in reinforcing positive behaviors and encouraging progress. However, it is not the most essential aspect initially for establishing trust. Positive feedback is more effective when the patient already feels understood and supported by the nurse.

A. Is from another state and says they are here on a long vacation. B. Has a cell phone that is not working in the emergency department. C. Is accompanied by a family member who will not let the client answer questions. D. Speaks another language and is in need of an interpreter to translate. E. None F. None

Correct Answer is C

Explanation

d. Speaks another language and is in need of an interpreter to translate.

The correct answer is c. Is accompanied by a family member who will not let the client answer questions.

Choice A Reason: Is from another state and says they are here on a long vacation

This choice is not necessarily indicative of human trafficking. While being from another state and claiming to be on a long vacation might raise some questions, it is not a definitive sign of trafficking. Many people travel for various reasons, and this alone does not suggest that the person is a victim of human trafficking.

Choice B Reason: Has a cell phone that is not working in the emergency department

This choice is also not a strong indicator of human trafficking. A non-working cell phone can be due to many reasons, such as technical issues or lack of service. While traffickers may sometimes control their victims’ communication devices, this alone is not enough to suspect trafficking.

Choice C Reason: Is accompanied by a family member who will not let the client answer questions

This choice is a strong indicator of human trafficking. Traffickers often control their victims’ interactions with others, including healthcare providers. If a family member or companion is overly controlling and does not allow the client to speak for themselves, it raises a significant red flag for potential trafficking. This behavior is often seen in trafficking situations to prevent the victim from disclosing their true circumstances.

Choice D Reason: Speaks another language and is in need of an interpreter to translate

This choice is not a definitive sign of human trafficking. Many people who are not victims of trafficking may speak another language and require an interpreter. While language barriers can complicate communication, they do not alone indicate trafficking. However, if combined with other signs, it could contribute to a suspicion of trafficking.

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The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

Correct Answer is B

Explanation

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

Correct Answer is C

Explanation

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