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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Rapid, continuous speech is a common symptom of manic behavior, as individuals may feel an increased pressure to speak.
Choice B reason: Flirtatious interaction can be part of the increased sociability and decreased inhibition associated with mania.
Choice C reason: Dressing in black or grey clothing is not specifically indicative of manic behavior.
Choice D reason: Sleeping for long periods is more commonly associated with depressive episodes, not manic behavior.
Choice E reason: Spending large sums of money recklessly can be a sign of the impulsivity and poor judgment that accompany manic episodes.
Correct Answer is C
Explanation
Choice A reason: Supportive and encouraging relationships are typically protective against the development of eating disorders, not a contributing factor?.
Choice B reason: Having multiple siblings in the household does not directly indicate a cause for an eating disorder.
Choice C reason: A family's lack of interest can contribute to feelings of neglect or low self-worth, which are known risk factors for the development of eating disorders?.
Choice D reason: While overprotective parents can contribute to stress, they are not necessarily an indicator of why a client may be experiencing an eating disorder. The relationship between parenting style and eating disorders is complex and not solely causative?.
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