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 that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

A. Reinforce statements regarding a will to live and realistic plans for the future. B. Discuss the client’s suicide plan. C. Limit time allowed to play video games. D. Encourage the client to discuss thoughts and feelings about wanting to die. E. Restrict visitors to family members only.

Correct Answer is ["A","B","D"]

Explanation

Rationale for A: Reinforcing a will to live and encouraging realistic future plans can promote hope and motivation in a depressed adolescent.

Rationale for B: Discussing the client’s suicide plan is essential for assessing risk and ensuring safety. It allows for intervention if the risk is significant.

Rationale for C: While managing screen time can be beneficial, it is less critical than addressing the underlying emotional issues and ensuring safety.

Rationale for D: Encouraging the client to express thoughts and feelings about wanting to die can provide a safe space for the adolescent to discuss suicidal ideation and help the nurse assess risk more effectively.

Rationale for E: Restricting visitors may not be helpful; maintaining social connections can provide support and reduce feelings of isolation.

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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

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Correct Answer is D

Explanation

Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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

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