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.
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Related Questions
Correct Answer is D
Explanation
A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.
Correct Answer is B
Explanation
A. While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B. Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D. While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.
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