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. Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B. Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D. Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.

A. Reinforce personal strengths observed in the client. B. Suggest ways to problem solve adapting to the new home. C. Help the client know they will not always feel this way. D. Inquire respectfully about the events of the departure.

Correct Answer is D

Explanation

A. Reinforcing personal strengths is a positive intervention, but in this context, understanding the underlying cause of anxiety should take precedence.
B. Suggesting ways to problem-solve adapting to the new home is a valuable intervention, but assessing the specific stressors or traumas the client may have experienced is more immediate.
C. Helping the client know they will not always feel this way is supportive, but understanding the context and potential triggers for anxiety is the first step.
D. Inquiring respectfully about the events of the departure is the most important initial intervention to gather information about potential traumatic experiences that may be contributing to the client's anxiety.

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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

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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