A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?

"Are you experiencing a relapse?"

"What time was your last drink?"

"How long have you had a problem with alcohol?"

"Are you having any liver problems?"

Answer and Explanation

The Correct Answer is B

A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.

B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.

C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.

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Correct Answer is A

Explanation

A. This outcome is specific, measurable, and timebound. It addresses the client's impaired social interactions and sets a realistic expectation for improvement within a short timeframe.
B. While this outcome is specific, it may not be achievable within a short timeframe and may not directly address the issue of egocentrism.
C. This outcome focuses on verbalization but may not necessarily lead to actual interaction or address the issue of egocentrism.
D. While this outcome is relevant, it is not as specific or timebound as option A.

A. Institute reverse isolation B. Withhold the next dose of medication C. Begin high protein, high cholesterol diet D. Notify health care provider stat

Correct Answer is D

Explanation

A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.

B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.

C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.

D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.

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A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with bipolar II disorder has a problem statement of impaired social interactions related to egocentrism. Which short-term correctly written outcome is an appropriate expectation for this client problem?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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