Author Question: A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which ... (Read 39 times)

LCritchfi · **on:** Jul 19, 2018

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 · **Reply #1 on:** Jul 19, 2018

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.