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. 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.

A. Explain to the client that her behavior invades the rights of the nursing staff. B. Teach the client strategies to control her obsessive-compulsive behavior. C. Ask the client to explain why she is keeping a detailed record of her nursing care. D. Encourage the client to express her feelings regarding the upcoming procedure. E. None F. None

Correct Answer is D

Explanation

A. Explain to the client that her behavior invades the rights of the nursing staff: This approach is confrontational and dismisses the client’s coping mechanism. It does not promote a therapeutic nurse-client relationship.

B. Teach the client strategies to control her obsessive-compulsive behavior: This is not the appropriate time for teaching behavioral strategies, especially when the client is experiencing stress related to an upcoming invasive procedure.

C. Ask the client to explain why she is keeping a detailed record of her nursing care: While this might offer insight, it can come across as intrusive or judgmental. It also shifts the focus away from emotional support.

D. Encourage the client to express her feelings regarding the upcoming procedure: Clients with obsessive-compulsive personality disorder often rely on control and orderliness to manage anxiety. The nurse should recognize that the client’s behavior may be a coping mechanism for procedure-related stress. Encouraging expression of feelings promotes trust and addresses the underlying 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

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?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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