A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

Administer disulfiram immediately.

Place in a side-lying position with the head of the bed elevated.

Give lorazepam PRN for signs of withdrawal.

Provide thiamine and folate supplements as prescribed.

Answer and Explanation

The Correct Answer is B

A.   Administering disulfiram is not the priority in the immediate care of a client with a closed head injury and elevated blood alcohol level. The focus should be on ensuring the client's safety and preventing complications related to the head injury.
B.   Placing the client in a side-lying position with the head of the bed elevated is crucial to prevent aspiration and maintain airway patency in a client who is difficult to arouse due to alcohol intoxication.
C. Giving lorazepam for signs of withdrawal may be necessary but does not address the immediate risk of aspiration in a client with altered consciousness.
D.   Providing thiamine and folate supplements is important for clients with alcohol use disorders, but the priority in this scenario is airway protection and preventing complications related to the head injury.

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Correct Answer is D

Explanation

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

A. Subconscious blame toward the client for staying in an abusive relationship. B. Difficulty accepting the explanation about how the injuries actually occurred. C. Experience in caring for clients who are affected by family violence is limited. D. Feelings are influencing the client’s care due to a personal history of abuse.

Correct Answer is A

Explanation

A. Feeling angry, embarrassed, and helpless may indicate subconscious blame or judgment toward the client for staying in an abusive relationship. It's important for the nurse to recognize and address these feelings to provide non-judgmental and supportive care.
B. Difficulty accepting the explanation about how the injuries occurred could contribute to these feelings, but it is not the primary cause in this context.
C. Limited experience in caring for clients affected by family violence may contribute to discomfort, but it does not explain the specific emotions described.
D. While a personal history of abuse could impact the nurse's feelings, the question is asking for the immediate cause of the emotions during the current interaction with the client.

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A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct Answer is D

Explanation

The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

Correct Answer is A

Explanation

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