A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions Could the nurse identify as the priority?

Helping the client identity positive personality traits

Providing for adequate hydration and rest

Educating the client about the consequences of alcohol misuse

Confronting the use of denial and other defense mechanisms

Answer and Explanation

The Correct Answer is B

While addressing self-esteem and positive personality traits is important for overall psychological well-being, it is not the priority during the acute detoxification phase. Ensuring the client's physical safety and stability is the immediate concern.

B. Providing for adequate hydration and rest.

Explanation: The process of detoxification from alcohol can lead to withdrawal symptoms, some of which can be severe and even life-threatening. Adequate hydration is crucial during this period to prevent dehydration and electrolyte imbalances that can occur due to excessive vomiting, diarrhea, or sweating associated with withdrawal. Rest is also important to help the client's body recover from the physical stress of withdrawal.

C. Educating the client about the consequences of alcohol misuse.

Education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but this intervention can come after addressing the immediate physical needs of detoxification.

D. Confronting the use of denial and other defense mechanisms.

Addressing denial and defense mechanisms is a critical aspect of therapy for clients with alcohol use disorder, but it might not be the first priority during the detoxification phase. Ensuring the client's physical safety and managing withdrawal symptoms take precedence initially.

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Correct Answer is A

Explanation

A. Plan the client's schedule to allow time for rituals.

Explanation:

For individuals with obsessive-compulsive disorder (OCD), engaging in rituals or repetitive behaviors can be a way to manage anxiety. Allowing time for these rituals within the client's schedule, while gently working towards reducing their impact, is a part of a gradual therapeutic approach known as Exposure and Response Prevention (ERP). ERP aims to help the client gradually face their anxiety triggers while refraining from engaging in compulsions.

Why the other choices are incorrect:

B. Confront the client about the senseless nature of the repetitive behaviors.

Confrontation can increase the client's anxiety and resistance to treatment. Instead, the nurse should approach the client with understanding and gradually work on strategies to reduce the compulsive behaviors.

C. Isolate the client for a period of time.

Isolating the client is not a therapeutic approach for managing OCD. It can lead to increased distress and negatively impact their mental health. Inclusion and support are more effective strategies.

D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Setting strict limits may escalate the client's anxiety and could be counterproductive. It's important to work collaboratively with the client and apply evidence-based approaches like ERP to manage their symptoms effectively.

A. An adolescent client who throws objects at other clients B. An older adult client who is manic and crying due to overstimulation C. A school-age client who attempts to repeatedly bite staff D. An adult client following a suicide attempt

Correct Answer is D

Explanation

A. An adolescent client who throws objects at other clients:

Explanation: Seclusion is contraindicated for this client due to safety concerns. The behavior of throwing objects at others indicates a potential danger to both the client and others in a confined space. Placing the client in seclusion could escalate the situation and potentially lead to further harm.

B. An older adult client who is manic and crying due to overstimulation:

Explanation: Seclusion might be contraindicated for this client as well. Older adults experiencing manic behavior and emotional distress could be further traumatized by seclusion. Alternatives like providing a calm and soothing environment, along with appropriate medications, might be more beneficial for this client.

C. A school-age client who attempts to repeatedly bite staff:

Explanation: Seclusion is a potential option for this client. The repeated attempts to bite staff pose a risk of physical harm to both the client and staff members. Seclusion might be used as a last resort to ensure the safety of everyone involved.

D. An adult client following a suicide attempt:

Explanation: Seclusion is generally contraindicated for clients who have attempted suicide. Placing them in isolation can worsen feelings of despair and isolation, potentially increasing the risk of self-harm or suicide. These clients require close monitoring, support, and therapeutic interventions to address the underlying issues.

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A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions Could the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

Correct Answer is A

Explanation

A nurse in an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

Correct Answer is D

Explanation

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