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 D
Explanation
When collecting data from a female client who has anorexia nervosa, the nurse should expect a finding of low bone density.
Anorexia nervosa is an eating disorder characterized by self-starvation, distorted body image, and a fear of gaining weight. Clients with anorexia nervosa are at risk for severe malnutrition, which can lead to a variety of complications, including bone loss and osteoporosis.
Options A, B, and C are incorrect findings in a client with anorexia nervosa. Decreased cholesterol levels may be an indication of malnutrition. Heavy monthly periods, or menstrual irregularities, may occur in clients with anorexia nervosa because of the hormonal changes that can result from severe weight loss. Elevated serum potassium levels are not a common finding in a client with anorexia nervosa.
Correct Answer is C
Explanation
"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.
Option A: "Display disapproval toward the perpetrator" - Not appropriate for the clinical setting
Option B: "Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting
Option D: "Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.
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