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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?
- A. Assess intake and output.
- B. Monitor for wheezing and apnea.
- C. Limit visitors to family members only.
- D. Assign the client to a teen support group.
Correct Answer: B
Rationale: Monitoring for wheezing and apnea is crucial during the first 24 hours of heroin detoxification to ensure respiratory stability, addressing immediate physiological risks.
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An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?
- A. Level of activity.
- B. The interactions with others.
- C. The emotional quality of attitude.
- D. Appetite.
Correct Answer: C
Rationale: The emotional quality of attitude reflects the client's internal state and is a key indicator of the antidepressant's impact on their depressive symptoms, making it the most critical aspect to assess.
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?
- 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.
Correct Answer: D
Rationale: Encouraging the client to express feelings regarding the upcoming procedure addresses potential anxiety driving the behavior, offering a therapeutic approach.
An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?
- A. Encourage the client to weigh herself daily at bedtime.
- B. Recommend exercise and recreation in the morning.
- C. Allow the client to select an arts and crafts activity.
- D. Put the client in charge of choosing snacks for the unit.
Correct Answer: C
Rationale: Allowing the client to select an arts and crafts activity provides a positive, non-food-related outlet for expression, supporting therapeutic engagement.
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
- A. Determine the client's reason for attempting suicide.
- B. Obtain the client's serum hydrocodone/acetaminophen level.
- C. Encourage the client to increase fluid intake.
- D. Observe the client for further narcotic effects.
Correct Answer: A
Rationale: Determining the client's reason for attempting suicide is the highest priority to understand underlying issues and plan appropriate interventions to prevent recurrence.
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?
- A. Allow the client to rest and sleep.
- B. Begin planning for the client's discharge.
- C. Encourage verbalization of feelings.
- D. Ensure the client attends groups addressing coping skills for dealing with depression.
Correct Answer: A
Rationale: Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate depression symptoms, addressing immediate physical needs.