A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?

Place the client in a private room.

Determine the client's level of disorientation.

Pad the side rails of the bed with towels.

Accompany the client when ambulating.

Answer and Explanation

The Correct Answer is D

Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.

Choice A, placing the client in a private room, does not address the client’s physical needs.

Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.

Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.

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Correct Answer is A

Explanation

Sertraline is a medication used to treat depression and other mental health conditions that can cause unwanted side effects. Excessive sweating and muscle twitching are potential side effects that should be immediately reported to the healthcare provider. A dry cough is a common side effect of other medications and not specific to sertraline.
Decreasing sodium intake is not necessarily related to the medication, and harmless, temporary changes in the ability to taste and smell are not significant enough to warrant special mention.

Choice B, "This medication can cause a dry cough," is a potential side effect of other medications and may cause confusion as to what medication the client is taking.
Choice C, "I need to decrease my sodium intake while on this medication," is not likely a statement related to sertraline but to other medications or medical conditions.
Choice D, "This medication can cause harmless, temporary changes to my ability to taste and smell," while accurate, is not the most critical information for the client to know about and may cause confusion as to what the client should report to the provider.

A. Assure that child has a large variety of caregivers. B. Establish a reward system for positive behavior. C. Provide a flexible schedule to adjust to the child's interests. D. Allow for imaginative play with peers without supervision.

Correct Answer is B

Explanation

The nurse should recommend establishing a reward system for positive behavior when contributing to the plan of care for a child with an autism spectrum disorder. Reward systems can be particularly effective for children with autism spectrum disorder, as they respond well to structured routines and consistency.

Choice A, assuring that the child has a large variety of caregivers, is not recommended, as children with autism spectrum disorder can be particularly sensitive to changes in routine and caregivers. Providing a flexible schedule to adjust to the child's interests,

choice C may be appropriate in some cases, but a structured routine can be even more beneficial. Allowing for imaginative play with peers without supervision, choice D, may not be safe or effective in all situations. It is important for the nurse to work with the child, their family, and other healthcare professionals to develop an individualized plan of care that meets the child's specific needs and goals.

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A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the client indicates an understanding of the information provided about sertraline?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a child who has autism spectrum disorder. Which of the following interventions should the nurse recommend for the plan of care?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

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A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?

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