The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

Walt for the client to respond.

Ask if the client heard the question.

Ask a different question.

Return at a later time to talk.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.

Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.

Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.

Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.

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Correct Answer is C

Explanation

Choice A rationale: A body mass index (BMI) of 21 is within the normal range and does not require immediate notification to the healthcare provider.

Choice B rationale: A blood pressure of 110/70 mm Hg is within the normal range for an adolescent and does not require immediate notification.

Choice C rationale: A potassium level of 2.9 mEq/dL (2.9 mmol/L) is below the normal range (hypokalemia) and requires notification to the healthcare provider due to the potential for adverse effects on cardiac and neuromuscular function.

Choice D rationale: A WBC of 10,000/mm3 (10 x 109/L) falls within the normal range and does not require immediate notification.

A. Gastric lavage. B. Renal dialysis. C. Nebulizing with albuterol. D. Administration of naloxone.

Correct Answer is D

Explanation

Choice A rationale: Gastric lavage may be considered, but the priority is to address respiratory depression. Naloxone administration is more immediate.

Choice B rationale: Renal dialysis is not indicated for the overdose of methadone and benzodiazepines. Addressing respiratory depression is the priority.

Choice C rationale: Nebulizing with albuterol is not the appropriate intervention for respiratory depression due to drug overdose. Naloxone administration is more critical. Choice D rationale: Administration of naloxone is the priority for this client with respiratory depression due to the potential opioid overdose (methadone). Naloxone is an opioid antagonist that can reverse opioid-induced respiratory depression.

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The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?

Correct Answer is D

Explanation

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