A nurse cares for a rape victim who was given flunitrazepam ...

[LCritchfi]

A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
 
  a. Coma
  b. Seizures
  c. Hypotonia
  d. Respiratory depression

Question 2

A patient states: I'm not worth anything. I have negative thoughts about myself. I want to go to sleep and never wake up. Which nursing intervention has the highest priority?
 
  a. Self-esteem building activities
  b. Anxiety self-control measures
  c. Sleep enhancement activities
  d. Suicide precautions

[bfulkerson77]

Answer to Question 1

D
Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma.

Answer to Question 2

D
The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse would also be expected to monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem while giving priority attention to suicide self-restraint.

[LCritchfi]

Thanks for the timely response, appreciate it

[chereeb]

Excellent