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 C

Explanation

A. Discuss the problem in a community meeting with the other clients on the unit present.

While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.

B. Escort the client to her room each time the nurse observes the client socializing with other clients.

This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.

C. Talk to the client and identify the specific limits that are required of the client's behavior.

This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.

D. Tell the other clients to ignore the client's lies.

While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.

A. Nystagmus B. Illusions C. Polyphagia D. Tremors E. Seizures

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

Explanation

A. Nystagmus: Nystagmus is not a typical manifestation of alcohol withdrawal. It is more commonly associated with intoxication or neurological conditions. Therefore, it is not included in the effects of alcohol withdrawal.

B. Illusions: Illusions (misinterpretations of external stimuli) are common during alcohol withdrawal, especially in severe cases such as withdrawal delirium (delirium tremens). Clients may misinterpret shadows or objects as threatening.

C. Polyphagia: Polyphagia (excessive eating) is not a recognized manifestation of alcohol withdrawal. Clients with withdrawal may experience nausea or a lack of appetite rather than an increased appetite.

D. Tremors: Tremors, often called "the shakes," are one of the most common early signs of alcohol withdrawal. They usually begin within hours after alcohol cessation.

E. Seizures: Seizures, specifically generalized tonic-clonic seizures, are a serious complication of alcohol withdrawal. They can occur within 6–48 hours after the last drink and are part of alcohol withdrawal syndrome.

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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

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Explanation

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

Explanation

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