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 A

Explanation

A. Disulfiram should be taken each morning, and it is recommended to start it 48 hours after the last drink of alcohol to prevent a severe reaction. This helps establish a clear association between the medication and alcohol avoidance.
B. While taking disulfiram with water is generally advisable, the crucial aspect is the timing and the initial 48-hour abstinence period.
C. Taking the medication at bedtime or limiting alcohol to one ounce daily does not address the specific timing requirement for disulfiram initiation.
D. Beginning the medication immediately and taking it daily, regardless of alcohol consumption, may not establish the necessary 48-hour alcohol-free period before starting disulfiram.

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

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

Correct Answer is A

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

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?