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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Neologisms refer to made-up words or phrases that have meaning only to the individual. The client's response does not include invented terms but rather consists of real words that are nonsensically grouped.
B. Echolalia is the repetition of words or phrases spoken by others. The client's response does not reflect repetition of the nurse's words but rather a disjointed response of their own.
C. Pressured speech involves rapid and often incoherent speech that reflects a sense of urgency. The client's response lacks the rapid flow characteristic of pressured speech.
D. Clang association is characterized by speech in which the individual connects words based on their sound rather than their meaning. The client's response ("medications, abbreviations, deviations, mediations") demonstrates this pattern, as the words are linked by similar sounds rather than by content or coherent thought.
Correct Answer is C
Explanation
A) Incorrect. This statement is a straightforward denial rather than rationalization.
B) Incorrect. This response is an example of avoidance or distraction, not rationalization.
C) Correct. Rationalization involves offering logical or reasonable explanations to justify behaviors or actions that might otherwise be unacceptable. In this case, the client is rationalizing her alcohol consumption as a means to relax and cope with the day treatment.
D) Incorrect. This statement reflects a defensive response but is not an example of rationalization.
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