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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B. The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D. Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.

A. Decreased prothrombin time and partial thromboplastin levels B. Increased values of serum levels for liver function profile C. Increasingly larger amounts of alcohol are needed to feel drunk D. Periodic indigestion with negative occult blood in stool. E. Memory lapses of events that occurred when drinking.

Correct Answer is ["B","C","D","E"]

Explanation

A. Chronic alcohol use is more likely to be associated with increased prothrombin time and partial thromboplastin levels due to impaired liver function.
B. Increased values of serum levels for liver function profile (such as AST, ALT, GGT) are common in individuals with chronic alcohol dependency.
C. Tolerance, where increasingly larger amounts of alcohol are needed to feel drunk, is a characteristic feature of alcohol dependency.
D. Periodic indigestion and negative occult blood in the stool may be indicative of alcohol- related gastrointestinal issues.
E. Memory lapses, especially blackouts or amnesia regarding events that occurred during drinking, are common in chronic alcohol use and dependency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

Correct Answer is D

Explanation

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

Correct Answer is ["B","C","D","E"]

Explanation

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