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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Related Questions
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.
Correct Answer is D
Explanation
Choice A reason:Citing personal reasons, such as needing to get home to family, is unprofessional and shifts focus away from the client’s needs. It does not address the client’s request or provide a constructive solution, making it an inappropriate response.
Choice B reason:Offering to do whatever the nurse can to help is vague and could imply willingness to perform prohibited tasks like shopping. This response risks crossing professional boundaries and is not appropriate.
Choice C reason:Suggesting the client wait for days when they feel better dismisses their current fatigue and inability to shop. It fails to offer immediate support or solutions, which is not helpful for an older adult needing assistance.
Choice D reason:Proposing to explore other resources, such as community services or family support, is appropriate because it respects the nurse’s professional boundaries while addressing the client’s needs. This response empowers the client by connecting them with sustainable solutions.
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