A nurse is admitting a client who has an alcohol use disorder. Which of the following actions should the nurse take first?

Determine the client's degree of physical dependence.

Discuss the treatment plan with the client.

Document the client's alcohol use in the medical record.

Initiate a referral for treatment for alcohol use disorder.

Answer and Explanation

The Correct Answer is C

A. Determine the client's degree of physical dependence:
This action is important but usually comes after the initial assessment and documentation. Assessing the degree of physical dependence involves evaluating the client's withdrawal symptoms, tolerance, and other physical health parameters. It helps in planning the appropriate level of care, such as detoxification if needed.

B. Discuss the treatment plan with the client:
While discussing the treatment plan is crucial, it's typically done after gathering essential information about the client's alcohol use, medical history, and current condition. The treatment plan is tailored based on the gathered data, which includes documenting the client's alcohol use.

C. Document the client's alcohol use in the medical record:
This is the first step because it provides a formal record of the client's alcohol use history, including patterns and any associated complications. Documenting this information helps in comprehensive care planning and ensures that all healthcare providers involved in the client's treatment have accurate and up-to-date information.

D. Initiate a referral for treatment for alcohol use disorder:
Referrals are essential, but they usually follow the initial assessment and documentation. The referral process involves connecting the client with appropriate resources, such as addiction specialists, counselors, or support groups, based on the documented information and the client's needs.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hgb 10 g/dL
Anemia (low hemoglobin levels) is a common finding in individuals with anorexia nervosa due to inadequate nutrition, leading to a decreased production of red blood cells. Hemoglobin levels below the normal range are often seen in people with severe malnutrition, such as those with anorexia nervosa.

B. Blood glucose 100 mg/dL:
A blood glucose level of 100 mg/dL is within the normal range. Anorexia nervosa typically does not cause specific changes in blood glucose levels.

C. TIBC 11 mcg/dL:
Total Iron-Binding Capacity (TIBC) is a test that measures the blood's capacity to bind to iron. The given value of 11 mcg/dL is unusually low and might not be within the typical reference range. However, the significance of this value is not clear without the specific reference range for the laboratory performing the test.

D. Potassium 3.7 mEq/L:
A potassium level of 3.7 mEq/L is within the normal range. Electrolyte imbalances, including low potassium levels (hypokalemia), can occur in individuals with anorexia nervosa due to inadequate intake and purging behaviors. While this level is within the normal range, individuals with anorexia nervosa may still exhibit electrolyte imbalances that require monitoring and management.

A. Implement consequences until the client takes the medication. B. Inform the client that he does not have the right to refuse the medication. C. Offer the client the medication at the next scheduled dose time. D. Administer the medication to the client via IM injection.

Correct Answer is C

Explanation

A. Implement consequences until the client takes the medication:
Punitive measures should never be used in healthcare, especially in the context of mental health treatment. Coercion and punitive consequences can lead to mistrust and hinder the therapeutic relationship, which is crucial in mental health care.

B. Inform the client that he does not have the right to refuse the medication:
While it's important for the client to understand the potential consequences of refusing medication, it's also crucial to respect the client's autonomy and right to make decisions about their own treatment. Involuntary admission doesn't negate the individual's right to be informed and involved in their care decisions to the extent they are able.

C. Offer the client the medication at the next scheduled dose time:
Respecting the client's autonomy is a fundamental ethical principle in nursing care. The nurse should continue to offer the medication to the client at the scheduled times. It's essential to maintain open communication with the client, addressing concerns and attempting to build trust, which can sometimes lead to the client accepting the medication voluntarily.

D.Administer the medication to the client via IM injection:
Administering medication against a patient's will is ethically and legally questionable without proper authorization, especially if the patient is not an immediate danger to themselves or others. This approach should be avoided whenever possible.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is admitting a client who has an alcohol use disorder. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?

A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?

A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

A nurse is caring for a client who has alcohol use disorder and is experiencing acute withdrawal. Which of the following medications should the nurse expect to administer first?

A nurse is reviewing the medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?

A nurse is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take?

A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?