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A nurse in a mental health facility is admitting a client.

Exhibits

A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Blood alcohol level

Client's recent loss

Smoking history

Client's recent consumption of alcohol

Cardiac assessment

Neurological assessment

Genitourinary assessment

Respiratory assessment

Gastrointestinal assessment

Answer and Explanation

Correct Answer : A,B,D,F,I

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E.   Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F.   The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G.   Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

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Correct Answer is C

Explanation

A. Meeting one's own needs without manipulating others may be a desirable outcome but is not specific to the core deficits of autism spectrum disorder.

B. Acknowledging that delusions are not real is more relevant to psychotic disorders rather than autism spectrum disorder.
C. Initiating social interactions with caregivers is an appropriate outcome for individuals with autism spectrum disorder, as it reflects improved social communication skills and social engagement.
D. Individuals with autism spectrum disorder may have difficulty understanding and responding to peer pressure, so changing behavior as a result of peer pressure may not be a realistic or desirable outcome.

A. Assign the same staff members daily to provide care for the client. B. Explore feelings of abandonment. C. Avoid discussing maladaptive behaviors with the client. D. Encourage dependent behaviors.

Correct Answer is A

Explanation

A. Consistency in staffing helps establish a therapeutic relationship and promotes trust and predictability, which can improve social interactions for clients with borderline personality disorder.
B. Exploring feelings of abandonment may be appropriate in therapy sessions but is not specifically aimed at improving social interactions.
C. Discussing maladaptive behaviors and working towards behavior change is important in the treatment of borderline personality disorder and should not be avoided.
D. Encouraging dependent behaviors can perpetuate maladaptive patterns and hinder progress in treatment for clients with borderline personality disorder.

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A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Nursing Test Bank

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Correct Answer is C

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Correct Answer is A

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A nurse in a mental health facility is admitting a client.

Exhibits

A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.