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 B

Explanation

The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.

choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.

choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.

choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.

A. Hypotension B. Narrowing pulse pressure C. Decreased level of consciousness D. Anuria

Correct Answer is B

Explanation

Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.

Choice A is not an answer because hypotension is a later sign of shock 2.

Choice C is not an answer because a decreased level of consciousness is also a later sign of shock.

Choice D is not an answer because anuria, or the absence of urine production, is also a later sign of shock

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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

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Correct Answer is B

Explanation

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