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.
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Correct Answer is C
Explanation
"I watch the television in my bedroom to help me sleep." This technique requires further teaching as watching TV before sleep is a poor sleep hygiene habit. Clients should be advised to keep TVs, mobile phones, and other electronic devices out of the bedroom, as electronic devices can be a source of stimulation and disrupt a sleep routine. Adequate sleep hygiene techniques include going to bed and waking up at the same time every day, avoiding caffeine, nicotine, and alcohol, and engaging in physical activity early in the day. Reading for a few minutes or engaging in some other relaxing activity can reduce difficulty falling back to sleep.
Option A: "If I wake up at night, I go to another room and read for 20 minutes" - This is a good sleep hygiene habit
Option B: "I eat my evening meal at least 3 hours before I go to bed" - This is a good sleep hygiene habit Option D: "I have stopped taking naps in the afternoon" - This is a good sleep hygiene habit Each of the other options helps with good sleep hygiene but C will not help.
Correct Answer is B
Explanation
Methadone. Methadone is a synthetic opioid that can help reduce the symptoms of opioid withdrawal and prevent relapse.
Methadone acts on the same receptors as other opioids, but it has a longer duration of action and a lower potential for abuse. Methadone is given in controlled doses as part of an opioid treatment program.
The other choices are not correct because:
Choice A. Risperidone is an antipsychotic medication that has no effect on opioid withdrawal.
Choice C. Lithium carbonate is a mood stabilizer that is used to treat bipolar disorder and has no effect on opioid withdrawal.
Choice D. Disulfiram is a medication that inhibits the metabolism of alcohol and causes unpleasant reactions when alcohol is consumed. It has no effect on opioid withdrawal.
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