Nokea
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
- A. Determine the client's reason for attempting suicide.
- B. Obtain the client's serum hydrocodone/acetaminophen level.
- C. Encourage the client to increase fluid intake.
- D. Observe the client for further narcotic effects.
Correct Answer: A
Rationale: Determining the client's reason for attempting suicide is the highest priority to understand underlying issues and plan appropriate interventions to prevent recurrence.
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A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?
- A. Take the medication each morning beginning 48 hours after your last drink of alcohol.
- B. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication.
- C. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily.
- D. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol.
Correct Answer: A
Rationale: Disulfiram should be taken each morning, starting 48 hours after the last drink to prevent a severe reaction, establishing a clear association between the medication and alcohol avoidance.
A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?
- A. Allow the client to rest and sleep.
- B. Begin planning for the client's discharge.
- C. Encourage verbalization of feelings.
- D. Ensure the client attends groups addressing coping skills for dealing with depression.
Correct Answer: A
Rationale: Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate depression symptoms, addressing immediate physical needs.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A young woman who suddenly goes blind with no indication of organic pathology.
- B. An older adult who continuously complains of a headache and back pain.
- C. An adolescent who becomes extremely anxious about going outside.
- D. A middle-aged man who is complaining of shortness of breath and is diaphoretic.
Correct Answer: A
Rationale: Sudden blindness with no organic pathology is indicative of a conversion disorder, involving neurological symptoms without a neurological basis.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy.
- B. Demonstrates effective ways to cope with anxiety.
- C. Takes all antianxiety medications as prescribed.
- D. Learns methods of relaxation to reduce anxiety.
Correct Answer: B
Rationale: Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Disturbed sensory perception.
- B. Compromised family coping.
- C. Ineffective sexual patterns.
- D. Impaired environmental interpretation.
Correct Answer: A
Rationale: The client's statements suggest a distorted perception of reality, indicating disturbed sensory perception, which addresses potential psychosis and immediate safety concerns.