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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 D

Explanation

A. Weighing the client every other day may contribute to increased anxiety and fixation on weight, which is not recommended for clients with binge eating disorder.
B. Remaining with the client for 1 hour after meals may not be feasible or practical and may not directly address the underlying issues associated with binge eating disorder.
C. Offering snacks when the client is hungry may not address the underlying psychological issues driving binge eating behavior and may inadvertently reinforce unhealthy eating patterns.

D. Planning a menu with the client promotes collaboration, empowers the client to make healthier food choices, and fosters a sense of control over their eating habits, which are important aspects of managing binge eating disorder.

A. Inform the client about confidentiality rights. B. Establish boundaries between the nurse and the client. C. Set short- and long-term objectives for the future. D. Evaluate progress toward predetermined goals.

Correct Answer is D

Explanation

A. Informing the client about confidentiality rights typically occurs during the orientation phase of the therapeutic relationship, not the working phase.
B. Establishing boundaries between the nurse and the client is an ongoing process that occurs throughout the therapeutic relationship, not just during the working phase.
C. Setting short- and long-term objectives for the future typically occurs during the orientation phase and continues throughout the therapeutic relationship, not just during the working phase.
D. During the working phase of the therapeutic relationship, the nurse and client collaborate to achieve the goals identified during the orientation phase. The nurse evaluates the client's progress toward these goals and adjusts interventions as necessary to promote therapeutic outcomes.

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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.

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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.