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
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.
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