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. Usual level of activity and average sleep pattern. B. Blood pressure when sitting and standing. C. Dentures to determine if they are poorly fitted. D. Body weight over the past three months.

Correct Answer is C

Explanation

A. Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B. Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D. Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

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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

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Correct Answer is C

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)

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?

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?