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A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?
- A. Implement 24-hr one-to-one nursing observation.
- B. Document the client's behavior every 2 hr.
- C. Restrict interactions with other clients.
- D. Administer prescribed medication via the IM route.
Correct Answer: A
Rationale: Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm. This provides constant monitoring given the high-risk situation.
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A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. I can discuss a client's information with staff who have provided care in the past.
- B. A client retains the legal right to privacy of health information even after they have died.
- C. The provider must give consent to discuss health information with the client's family.
- D. A provider may speak to a client's employer regarding a substance use disorder.
Correct Answer: B
Rationale: Clients retain the legal right to privacy of health information even after death, per HIPAA regulations. This statement reflects an accurate understanding of confidentiality principles.
A client is becoming increasingly agitated
- A. anxious
- B. and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?
- C. Verbally de-escalate the client.
- D. Take the client to the seclusion room.
- E. Place the client in restraints.
- F. Obtain a prescription for haloperidol.
Correct Answer: A
Rationale: Verbally de-escalating the client is the first step to reduce agitation and prevent escalation. This non-invasive approach prioritizes safety and communication.
A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?
- A. I check my blood pressure once a week.
- B. I chew sugar-free gum several times daily.
- C. I haven't had a drink of alcohol since I started taking these injections.
- D. I spend several hours a day outside gardening when it's sunny.
Correct Answer: D
Rationale: Spending several hours outside in the sun could increase the risk of photosensitivity, a side effect of haloperidol. The nurse should address this to educate the client on protective measures like sunscreen use.
A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2.5
Rationale: Step 1: (50 mg ÷ 20 mg/mL) × 1 mL = 2.5 mL. The nurse should administer 2.5 mL to deliver the prescribed 50 mg dose, calculated based on the concentration of the available solution.
A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?
- A. Bupropion.
- B. Risperidone.
- C. Aripiprazole.
- D. Quetiapine.
Correct Answer: A
Rationale: Bupropion is an antidepressant also used to aid smoking cessation by reducing cravings and withdrawal symptoms. It’s specifically indicated for this purpose.