A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

The client will implement alternative strategies for managing anxiety.

The client will acknowledge alcohol dependence and need for treatment.

The client's withdrawal from alcohol will be managed without complications.

The client will rebuild damaged interpersonal relationships.

Answer and Explanation

The Correct Answer is C

A. The client will implement alternative strategies for managing anxiety.

While addressing anxiety is important for the overall well-being of the client, it may not be the highest priority in this context. The immediate physical safety of the client during alcohol withdrawal takes precedence over addressing anxiety.

B. The client will acknowledge alcohol dependence and need for treatment.

Recognizing alcohol dependence and the need for treatment is an important step, but it may not be the highest priority. It is more focused on the client's acceptance and understanding of their situation rather than addressing immediate health risks.

C. The client's withdrawal from alcohol will be managed without complications.

This is the correct answer. Managing alcohol withdrawal without complications is the highest priority goal in this scenario. Alcohol withdrawal can lead to severe physical symptoms, including seizures and delirium tremens, which can be life-threatening. Ensuring the safe and medically supervised management of withdrawal is crucial for the client's immediate well-being.

D. The client will rebuild damaged interpersonal relationships.

While repairing damaged relationships is important for the client's overall rehabilitation, it's not the highest priority in this context. Physical health and safety take precedence over addressing interpersonal issues.

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Correct Answer is A

Explanation

A.Lithium is excreted through the kidneys, and dehydration and sodium depletion increase the risk of lithium toxicity. A client who runs 4 miles outdoors every afternoon is at risk of excessive sweating and fluid loss, which can lead to dehydration and sodium depletion. This reduces lithium excretion, leading to toxic levels in the blood.

B. Anormal sodium intake helps maintain lithium balance. A low sodium intake increases lithium retention, but 2-3 grams/day is within the normal recommended range.

C. Adequate hydration helps prevent lithium toxicity. Clients on lithium should drink 2–3 liters of fluid daily to promote kidney function and lithium excretion.
D. Tyramine-rich foods (e.g., aged cheese, cured meats) are a concern for clients on monoamine oxidase inhibitors (MAOIs), not lithium. Tyramine does not affect lithium levels.

A. Ask the client to create her own schedule of daily activities. B. Teach the client to use passive communication when interacting with others. C. Determine the client's need for assistance with grooming. D. Limit the client's involvement in unit activities.

Correct Answer is C

Explanation

A. Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine.

The other options do not align with best practices for caring for a client with major depressive disorder:

B. Teaching passive communication is not appropriate, as assertive communication is typically encouraged to help the client express her needs and feelings effectively.

C.Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine

D. Limiting involvement in unit activities could further isolate the client and exacerbate her symptoms. Encouraging participation and engagement is generally more beneficial.

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A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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