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

Answer: A. "It sounds like you're having a difficult time."

Rationale:

A) "It sounds like you're having a difficult time":

This response is empathetic and acknowledges the client's distress. By validating the client's feelings, the nurse provides support and opens the door for further discussion about their anxiety and related symptoms. This approach can help the client feel understood and encourage them to share more about their experience.

B) "Have you talked to your provider about this yet?":

While it is important for the client to communicate their symptoms to their provider, this response might come across as dismissive of the client's immediate emotional state. It could be more supportive to first acknowledge the client's current experience before suggesting further actions.

C) "Everyone has trouble sleeping at times":

This response may minimize the client's concerns and fail to address their specific experience. It can come off as invalidating by suggesting that their situation is normal and not warranting further exploration or support.

D) "Why do you think you are so anxious?":

Asking why the client feels anxious might be perceived as interrogative rather than supportive. This approach could put pressure on the client to explain their feelings, which might not be productive if they are struggling to articulate their emotions or causes of anxiety.

A. "It must be very difficult for you to see your wife in pain." B. "I wish there was more that I could do to relieve your wife's pain, too." C. "I'm sure your wife will begin to feel better soon." D. "We're doing everything we can to keep your wife comfortable."

Correct Answer is A

Explanation

Answer: A

Rationale:

A) "It must be very difficult for you to see your wife in pain.": This response acknowledges the partner's feelings and provides emotional support. It shows empathy and validates the partner's experience, helping to build rapport and trust between the nurse and the family member.

B) "I wish there was more that I could do to relieve your wife's pain, too.": While this response expresses sympathy, it might unintentionally convey a sense of helplessness or inadequacy on the part of the nurse, which could increase the partner's anxiety or frustration.

C) "I'm sure your wife will begin to feel better soon.": This response is intended to be reassuring, but it can come off as dismissive of the partner's current concern and may not address their immediate emotional needs. It also makes a promise that the nurse cannot guarantee.

D) "We're doing everything we can to keep your wife comfortable.": This response provides factual information about the care being provided, but it does not address the partner's emotional distress. It focuses on the actions of the healthcare team rather than acknowledging the partner's feelings.

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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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