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. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.

B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.

A. An idea of reference B. A delusion of infidelity C. An auditory hallucination D. Echolalia

Correct Answer is A

Explanation

A) Correct. An idea of reference is a false belief that ordinary events, objects, or behaviors of others have a particular and unusual meaning directly pertaining to oneself. In this case, the client believes that the doctors' conversation in the hall is about them.

B) Incorrect. A delusion of infidelity involves a false belief that one's partner is being unfaithful.
C) Incorrect. Auditory hallucinations involve hearing things that are not present.
D) Incorrect. Echolalia is the repetition of another person's words.

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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

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

Correct Answer is A

Explanation

A newly admitted client diagnosed with paranoid schizophrenia is super vigilant and constantly scans the environment. The client states, "I saw doctors talking in the hall. They were plotting to kill me." Which of the following does the nurse correctly identify as this behavior?

Correct Answer is A

Explanation

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