A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Check the client's pupil reactivity.

Perform a developmental screening test.

Prepare the client for a CT scan.

Obtain a urine specimen.

Monitor the client’s vital signs frequently.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

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Free Nursing Study Resources

Correct Answer is ["B","C"]

Explanation

Choice A reason: While having a large number of pets can be a sign of hoarding, it is not necessarily a concern unless it negatively impacts the living conditions.

Choice B reason: Becoming angry and upset when attempting to remove items is a common reaction in individuals who hoard, indicating an emotional attachment to possessions.

Choice C reason: Inability to enter rooms due to clutter is a clear sign of hoarding, as it indicates that the accumulation of items has significantly interfered with the intended use of living spaces.

Choice D reason: Obsessive cleaning of the same areas may indicate a different issue, such as obsessive-compulsive disorder, rather than hoarding.

Choice E reason: Throwing away items deemed "unnecessary" is not typically associated with hoarding behavior, as hoarding involves difficulty parting with items.

A. A client who is unable to provide basic needs when resources are available. B. A client who acts only in their own interests. C. A client who is gravely disabled. D. A client with a severe intellectual developmental disorder. E. A client who is nonadherent to their medication regimen.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: A client unable to provide for basic needs, despite having resources, may lack the capacity to make informed decisions, necessitating a proxy decision-maker.

Choice B reason: Acting in one's own interest does not necessarily indicate an inability to make informed decisions about care.

Choice C reason: A gravely disabled client may not be able to comprehend the nature of their condition or the consequences of medical decisions, thus requiring assistance.

Choice D reason: Clients with severe intellectual developmental disorders often require a legal guardian to make healthcare decisions on their behalf.

Choice E reason: Nonadherence to medication could be due to various factors, including lack of understanding of the treatment plan, indicating the need for a decision-maker.

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A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

In the inpatient behavioral health unit, which clients require someone to make decisions regarding their medical and psychiatric care in their best interest? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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