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 B
Explanation
Choice A reason: Drooling is not a common side effect of amitriptyline; instead, dry mouth due to anticholinergic effects is more likely.
Choice B reason: Orthostatic hypotension is a well-documented adverse effect of amitriptyline, related to its action on the autonomic nervous system. Nurses should closely monitor for dizziness, falls, or fainting.
Choice C reason: Diarrhea is not a typical adverse effect of amitriptyline; constipation is more commonly seen because of anticholinergic properties.
Choice D reason: Metallic taste in the mouth is not a notable adverse effect of amitriptyline and is more often associated with other medications such as certain antibiotics.
Correct Answer is ["B","C"]
Explanation
Choice A reason:A stimulating environment can exacerbate symptoms during the manic phase of bipolar disorder, as it may increase agitation, impulsivity, or overstimulation. Instead, a calm, structured environment is recommended to help stabilize the client’s mood and behavior.
Choice B reason:Consistent unit routines provide predictability and structure, which are essential for clients in the manic phase. This helps reduce chaos, supports medication adherence, and promotes a sense of safety, aiding in mood stabilization.
Choice C reason:Discouraging daytime napping is appropriate because excessive sleep during the day can disrupt the client’s sleep-wake cycle, potentially worsening manic symptoms. Encouraging a regular sleep schedule supports overall stability in bipolar disorder management.
Choice D reason:Scheduling daily seclusion times is not a standard intervention for mania unless the client poses an immediate safety risk. Seclusion is typically a last resort and not a routine part of care, as it can increase agitation or feelings of isolation.
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