The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

Insert a nasogastric tube

Monitor airway and vital signs

Insert an indwelling urinary catheter or monitor output

Anticipate and treat hyperpyrexia with cooling measures

Answer and Explanation

The Correct Answer is B

B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.

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Correct Answer is A

Explanation

A. Conduct Disorder is characterized by a repetitive and persistent pattern of behavior that violates the rights of others or major age-appropriate societal norms or rules. It often includes aggressive behavior towards people or animals, destruction of property, deceitfulness or theft, and serious violations of rules.
B. Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by difficulties in social interaction and communication, as well as restricted and repetitive patterns of behavior, interests, or activities.
C. Oppositional behavior is present in ODD but the severity and nature of the behaviors described in the scenario (prostitution, running away, and abuse towards parents) are more consistent with Conduct Disorder rather than ODD.
D. Childhood depression, also known as pediatric depressive disorder, involves persistent feelings of sadness, hopelessness, or irritability that interfere with daily functioning.

A. Assess for past history of suicide attempts. B. Determine whether the client has a specific plan to commit suicide. C. Identify coping mechanisms. D. Notify all members of the treatment team and place the client on suicide precautions.

Correct Answer is D

Explanation

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

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The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client's parents reported that they have run away several times and is abusive towards them. The nurse should anticipate that the diagnosis will be:

Correct Answer is A

Explanation

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Correct Answer is D

Explanation

A client has been taking oxycodone for pain. The client has returned three times for refills of the prescription. In addition to slurred speech, which assessment leads the nurse to suspect opioid Intoxication?

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