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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A nurse discussing comorbidities associated with eating disorders with a newly licensed nurse should include depression, anxiety, and obsessive-compulsive disorder (OCD) in the discussion. Clients who have eating disorders often have comorbid psychiatric conditions.
Depression and anxiety are two common conditions among clients with eating disorders. OCD is another condition that is often associated with eating disorders. Clients with OCD may have obsessive thoughts about food intake, weight, and body image. These clients may also engage in compulsive behaviors related to eating, such as calorie counting or food restriction. Options C and E are incorrect because breathing-related sleep disorders and schizophrenia are not typically associated with eating disorders.
Correct Answer is D
Explanation
"The client reports his heart is beating out of his chest." as this symptom is consistent with anxiety and the client's prescription is for PRN anxiety. Alprazolam is a medication used to treat anxiety disorders and symptoms of anxiety.
Choice A, "The client pretends to be a government agent," is not a symptom that would be treated with alprazolam.
Choice B, "The client reports seeing bugs crawling on the walls," may indicate the presence of a hallucination or other mental health symptom, but is not related to anxiety and is not an appropriate indication for alprazolam.
Choice C, "The client describes an increase in pain after receiving meperidine," indicates a potential adverse drug effect and is not related to anxiety or an indication for alprazolam.
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