A 19-year-old client has been admitted to the ED after snorting ...

[vinney12]

A 19-year-old client has been admitted to the ED after snorting heroin with her boyfriend. She has pinpoint pupils and is unconscious. The client's priority nursing diagnosis is:
 
  1. Ineffective breathing pattern
  2. Risk for imbalanced fluid volume
  3. Impaired physical mobility
  4. Disturbed sensory perception

Question 2

When assessing a client for potential alcohol abuse problems, the nurse will seek the results of the most sensitive laboratory test for detecting the effects of chronic alcohol abuse, which is:
 
  1. Elevated erythrocyte mean corpuscular volume (EMCV)
  2. Serum glutamic-pyruvic transaminase (SGPT)
  3. Lactic dehydrogenase (LDH)
  4. Serum gamma-glutamyl transferase (GGT)

[amy.lauersdorf90]

Answer to Question 1

ANS: 1
Heroin intoxication is indicated by pinpoint pupils and decreased respirations. This is the priority diagnosis (option 1). Option 2, impaired fluid imbalance, and option 3, impaired physical mobili-ty, may be important at some time but not initially. Option 4 is not a priority at this time.

Answer to Question 2

ANS: 4
GGT (option 4) is the most sensitive marker for recent alcohol use. EMCV (option 1) can be an indicator of long-term alcohol use. SGPT (option 2) is an indictor of hepatic problems. LDH (op-tion 3) is an indicator of cardio isoenzymes.

[vinney12]

TYSM

[ricroger]

Gracias!