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
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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Related Questions
Correct Answer is D
Explanation
D. This response is consistent with the characteristics of antisocial personality disorder, which include a lack of remorse, as well as a tendency to rationalize behavior or blame others. Individuals with this disorder often fail to accept responsibility for their actions and may exhibit behaviors that are impulsive, reckless, and violate the rights of others without feeling guilty.
A. Individuals with antisocial personality disorder often lack remorse or empathy for the consequences of their actions and may not experience feelings of shame or guilt, even when their behavior results in harm to others.
B. Expressing genuine remorse or empathy for the harm caused to others is uncommon in individuals with antisocial personality disorder.
C. Claiming to have no memory of the behavior or the events leading up to it is a common defense mechanism used. This may serve to avoid accountability or responsibility for their actions, rather than indicating genuine memory impairment. However, it is not characteristic for antisocial personality disorder.
Correct Answer is B
Explanation
B. Oxazepam is a benzodiazepine and is often used for the management of alcohol withdrawal syndrome. It works by acting on the GABA receptors in the brain, which are the same receptors that alcohol affects, thus helping to alleviate withdrawal symptoms.
A. Fluoxetine is an antidepressant medication belonging to the class of selective serotonin reuptake inhibitors (SSRIs). It is primarily used to treat conditions like depression, anxiety disorders, obsessive- compulsive disorder (OCD), and bulimia nervosa. It is not typically used to manage alcohol withdrawal symptoms.
C. Buspirone is an anti-anxiety medication used to treat generalized anxiety disorder (GAD). It works differently from benzodiazepines and is not typically used to manage alcohol withdrawal symptoms.
D. Amitriptyline is a tricyclic antidepressant used to treat depression, neuropathic pain, and sometimes migraines. Like fluoxetine, it is not typically used to manage alcohol withdrawal symptoms.
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