A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
Obtain a blood specimen.
Implement seizure precautions.
Perform a neurological exam.
Insert an IV access site.
The Correct Answer is B
Choice A reason: Obtaining a blood specimen is important to assess electrolyte levels, liver function, or alcohol levels, but it is not the first priority in acute alcohol withdrawal. Immediate safety concerns, such as preventing seizures, take precedence.
Choice B reason: Acute alcohol withdrawal carries a high risk of seizures, which can be life-threatening. Implementing seizure precautions, such as ensuring a safe environment and having emergency medications available, is the first priority to protect the client from harm.
Choice C reason: Performing a neurological exam is valuable to assess the client’s mental status and neurological function, but it is not the first action. Addressing immediate risks like seizures is more urgent in the acute phase of withdrawal.
Choice D reason: Inserting an IV access site is important for administering fluids or medications, such as benzodiazepines, to manage withdrawal symptoms. However, ensuring seizure precautions are in place is a higher priority to address immediate safety risks.
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Correct Answer is D
Explanation
Choice A reason:Physical activity is beneficial for overall health and can support mental well-being by reducing stress and improving mood. However, it does not replace the need for antipsychotic medication, which is specifically designed to manage symptoms of serious mental health conditions like schizophrenia or bipolar disorder by targeting neurotransmitter imbalances.
Choice B reason:Antipsychotics do not cure mental illnesses. They are effective in managing symptoms, such as hallucinations or delusions, by stabilizing brain chemistry, but they do not address the underlying cause of the condition or eliminate it entirely. Most mental illnesses require long-term management, not a cure.
Choice C reason:Taking antipsychotics at bedtime may help reduce certain side effects, like drowsiness, for some patients. However, it does not universally prevent all side effects, as these medications can cause a range of issues, including weight gain, movement disorders, or metabolic changes, regardless of the time of administration.
Choice D reason:Adherence to antipsychotic medication is critical because skipping doses can disrupt the therapeutic levels of the drug in the body, leading to a relapse of symptoms such as psychosis, mania, or severe mood disturbances. Consistent use helps maintain stability and prevent worsening of the condition, making this the most important point to convey.
Correct Answer is C
Explanation
Choice A reason: The Hamilton Depression Scale is used to assess severity of depression, not antipsychotic side effects.
Choice B reason: The Body Attitude Test is used in eating disorder assessments, unrelated to risperidone therapy.
Choice C reason: The Abnormal Involuntary Movement Scale (AIMS) evaluates for movement disorders like tardive dyskinesia, which are possible side effects of antipsychotics. Baseline assessment is essential before starting treatment.
Choice D reason: The Recovery Attitude and Treatment Evaluator measures patient attitudes about recovery and treatment, not medication side effects.
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