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: While mood stabilizers are essential in treatment, medication cannot be safely administered before completing an assessment of risk and safety.
Choice B reason: The priority in this scenario is to assess safety, as John is at risk of harming himself or others due to reckless behavior during mania and suicidal ideation during depression. Safety always precedes treatment or education.
Choice C reason: Therapy is a valuable part of long-term management, but it is not the immediate priority when safety concerns exist.
Choice D reason: Education is important but cannot come before determining immediate risk and ensuring safety.
Correct Answer is A
Explanation
Choice A reason:A neologism is a made-up word or phrase that has meaning only to the person using it, often seen in schizophrenia. The client’s repeated use of "flakala," a non-existent word, indicates the creation of a term unique to their thought process, fitting the definition of a neologism.
Choice B reason:Word salad refers to a jumbled, incoherent string of words or phrases that lack meaningful connection, making communication difficult to understand. The client’s statement is repetitive and focused on a single invented word, not a disorganized mix of unrelated words, so this does not apply.
Choice C reason:Echolalia involves repeating words or phrases spoken by others, often seen in conditions like autism or schizophrenia. The client is not mimicking someone else’s speech but is using a self-created word, so echolalia is not the correct description.
Choice D reason:Clang association is when words are chosen based on their sound, such as rhyming or alliteration, rather than meaning. The client’s use of "flakala" does not involve sound-based word choices but rather the invention of a new word, making this choice incorrect.
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