An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
Assess intake and output.
Monitor for wheezing and apnea.
Limit visitors to family members only.
Assign the client to a teen support group.
The Correct Answer is B
A. Assessing intake and output is important for overall monitoring but does not address the specific concerns related to heroin detoxification.
B. Monitoring for wheezing and apnea is crucial during the first 24 hours after admission for heroin detoxification to ensure respiratory stability.
C. Limiting visitors is a general precaution but may not be the most important intervention related to the physiological effects of heroin detoxification.
D. Assigning the client to a teen support group is a valuable intervention for overall support but may not address the immediate physiological concerns of heroin detoxification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Helping clients identify areas of problem in their lives is more characteristic of the orientation phase of group development, where the group establishes trust and defines the purpose and goals.
B. Discussing ways to use new coping skills learned is appropriate during the working phase.
This phase focuses on problem-solving, decision-making, and achieving the goals identified in the orientation phase.
C. Establishing a rapport with group members is crucial during the orientation phase to build trust and create a safe environment for group members to share their experiences.
D. Clarifying the nurse’s role and clients’ responsibilities is more relevant in the orientation phase as the group establishes structure and guidelines.
Correct Answer is D
Explanation
A. Creatinine primarily reflects kidney function, not the metabolism of lithium in the liver.
B. Amitriptyline's effects on lithium toxicity are not directly related to creatinine levels.
However, both drugs can impact kidney function.
C. The decision to change medication based on creatinine levels involves assessing the impact on kidney function, not the combination of lithium and amitriptyline per se.
D. Lithium is excreted by the kidneys, and monitoring creatinine levels helps assess renal function, guiding the appropriate dosage and preventing lithium toxicity.
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