A female client is admitted with abdominal pain, possibly due to a gastric ulcer. Two days after admission, the client reports feeling nervous and tremulous. Further assessment reveals that the client's family is bringing a gin and tonic each night to help her relax. Which action(s) should the nurse take? Select all that apply.
Ask the client if she has any alcohol in the room at this time.
Administer an PRN prescription for an antianxiety drug.
Inform the family that they are enabling the client.
Observe for signs to determine if client is inebriated.
Schedule a conference with the client and family members.
Correct Answer : A,D,E
A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.
B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.
C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.
D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.
E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Glucose and calcium levels: During thyrotoxic crisis, the body’s metabolism is increased, which can lead to hyperglycemia. Additionally, calcium levels may fluctuate due to the impact of thyroid hormones on bone metabolism, making these values critical to monitor.
B. Electrolytes and hemoglobin: While monitoring electrolytes is important, they are not the most critical values in a thyrotoxic crisis. Hemoglobin levels are not directly impacted by thyroid storm and are less likely to provide essential insights for managing this condition.
C. Renal and liver function tests: While important for general health monitoring, renal and liver function tests are not the most critical in the immediate management of a thyrotoxic crisis. The focus should be on metabolic and electrolyte imbalances rather than organ function tests.
D. Blood and urine cultures: Blood and urine cultures are used to detect infections, they are not a priority during a thyrotoxic crisis unless there is a concern about infection. The primary focus should be on managing thyroid hormone levels and associated metabolic effects.
Correct Answer is A
Explanation
A. Determine how long the client has been lying prone: Prone positioning is used post-amputation to prevent hip flexion contractures. However, prolonged periods in this position can cause discomfort or complications. Knowing the duration helps evaluate if it’s appropriate to reposition or maintain it for therapeutic reasons.
B. Measure the client's vital signs: Vital signs are important in the postoperative period, but this task can be completed after addressing the client’s immediate request and assessing the potential impact of their current positioning on healing and comfort.
C. Inspect the dressing on the stump: Inspecting the stump is crucial for monitoring for infection or bleeding. However, unless there is a concern based on symptoms or reports from the client, it should follow assessment of position and comfort needs.
D. Assist the client in turning to a position of comfort: Turning the client without assessing how long they have been prone could interfere with therapeutic positioning aimed at preventing complications like hip contractures, especially in early postoperative care.
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