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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Correct Answer is C

Explanation

Choice A reason: Acrophobia is the fear of heights, which is not indicated by the client's fear of being outdoors alone.

Choice B reason: Xenophobia is the fear of strangers or foreigners, which does not align with the client's described fear.

Choice C reason: Agoraphobia is the fear of open spaces or being in crowded, public places like markets. It also includes the fear of leaving a safe place, such as home, which aligns with the client's symptoms.

Choice D reason: Mysophobia is the fear of germs, which is not related to the fear of being outdoors alone.

A. "I will restrict my intake of processed foods high in sodium." B. "I will drink 8 to 12 glasses of liquids daily." C. "I will take my medications with food." D. "I will have my blood drawn on schedule."

Correct Answer is B

Explanation

Choice A reason: Restricting sodium intake is not necessary with lithium carbonate, and maintaining a consistent sodium level is important to prevent lithium toxicity.

Choice B reason: Drinking excessive fluids can dilute lithium levels in the blood, potentially leading to subtherapeutic levels and reduced efficacy of the medication.

Choice C reason: Taking medications with food can help with absorption and minimize gastrointestinal side effects, but it is not specific to lithium carbonate.

Choice D reason: Having blood drawn on schedule is important for monitoring lithium levels and ensuring safe treatment.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is providing education to a client regarding a new prescription for lithium carbonate. Which statement by the client indicates the need for additional education?

Correct Answer is B

Explanation

A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa with a body mass index (BMI) of 17.2. Which of the following actions should the nurse take? Select all that apply.

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When engaging with clients, which techniques should the nurse avoid using to foster more therapeutic responses? Select all that apply.

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