Select the nursing intervention necessary after administering naloxone (Narcan) to a patient with an opiate overdose.

Correct Answer: A

Rationale: The correct answer is A: Monitor the airway and vital signs every 15 minutes. After administering naloxone to a patient with an opiate overdose, it is crucial to monitor the patient's airway and vital signs regularly to assess for respiratory depression, potential re-sedation, and other adverse effects of naloxone. This intervention ensures the patient's safety and allows for prompt detection and management of any complications. Choice B is incorrect because inserting a nasogastric tube and testing gastric pH is not indicated after naloxone administration for opiate overdose. Choice C is incorrect as treating hyperpyrexia with cooling measures is not a priority intervention in this scenario. Choice D is also incorrect as inserting an indwelling urinary catheter is not necessary after administering naloxone for opiate overdose.

Correct Answer: A

Rationale: The correct answer is A because for a patient who has ingested LSD, it is important to have someone stay with them and provide verbal support due to the potential for anxiety and panic attacks. This helps in grounding the patient and providing reassurance. On the other hand, for a patient who has ingested PCP, a regimen of limited contact with staff members is maintained to prevent potential aggression or unpredictable behavior. Continual visual monitoring is provided to ensure safety without directly engaging with the patient. Choice B is incorrect because placing a patient on one-on-one intensive supervision for PCP ingestion may escalate the situation due to potential paranoia or aggression. Choice C is incorrect because LSD ingestion may lead to sensory overload, so providing moderate sensory stimulation is more appropriate. Choice D is incorrect because restraints for LSD ingestion are not necessary and seizure precautions are not typically needed for PCP ingestion.

Correct Answer: A

Rationale: The correct answer is A: Chronic low self-esteem. The patient's statement reflects long-standing feelings of inadequacy and worthlessness, indicating a chronic issue rather than a temporary situation (situational low self-esteem). The statement also reveals a negative perception of self, which aligns with chronic low self-esteem. Disturbed personal identity refers to confusion in one's sense of self, which is not evident in the patient's statement. Ineffective health maintenance pertains to the inability to identify, manage, and seek help for health problems, which is not the primary issue in this scenario. Therefore, A is the most appropriate nursing diagnosis.

Correct Answer: A

Rationale: The correct answer is A because actively listening allows the nurse to show empathy, understanding, and respect towards the client, which are essential for building a therapeutic relationship. By actively listening, the nurse can demonstrate genuine interest in the client's thoughts and feelings, fostering trust and rapport. Choice B is incorrect as intervening when the client expresses beliefs from their illness may disrupt the client's expression and hinder the development of trust. Choice C is incorrect because evaluating behaviors and relationships may create a sense of judgment and lack of privacy, which can be detrimental to the therapeutic relationship. Choice D is incorrect because passively allowing the client to control communication may lead to a lack of direction and boundaries, potentially hindering effective communication and rapport-building.

Correct Answer: D

Rationale: The correct answer is D because having one's only child leave home to attend college is an example of a maturational crisis. This event represents a significant life transition that can trigger emotional distress and force a reevaluation of one's identity and roles as a parent. It is a normal developmental milestone that signifies a shift in family dynamics and requires adjustment to an empty nest. A: Experiencing an unplanned pregnancy is not a maturational crisis as it is more related to a situational crisis. B: Losing one's job within months of retiring is not a maturational crisis but rather a situational crisis related to financial security. C: Working at a bank that was recently robbed is not a maturational crisis but a situational crisis related to work safety and stress.