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. Telling the client to call Adult Protective Services is a valid intervention, but immediate safety planning is crucial.
B. Verifying the client's report by determining physical evidence is important but may not be the most immediate and practical intervention.
C. Referring the client to a program for victims of domestic violence is a valuable option, but immediate safety planning should take precedence.
D. Assisting the client in developing an emergency safety plan is the most important intervention to ensure the client's safety in the present situation.

A. A nurse who works in a pediatric emergency department. B. An adolescent male whose parents recently divorced. C. A retired older male whose significant other has passed away. D. A single working mother with three preschool-aged children.

Correct Answer is B

Explanation

A. While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B. Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D. While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

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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

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

Which individual should the nurse consider at the highest risk for suicide?

Correct Answer is B

Explanation

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

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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?

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)