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.

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Correct Answer is B

Explanation

A. Paranoia:
Paranoia involves unfounded beliefs that others are plotting against, persecuting, or harming the individual. It is not directly related to the client's statement about bodily sensations.

B. A somatic delusion:
This is the correct choice. A somatic delusion is a false belief related to the body. In this case, the client believes that their heart exploded and blood is draining out, which is a somatic delusion involving bodily functions and sensations.

C. Concrete thinking:
Concrete thinking refers to a literal and straightforward way of thinking without the ability to interpret abstract or metaphorical language. While the client's statement is literal, it is not an example of concrete thinking. Concrete thinking would involve an inability to understand figurative language, which is not the case here.

D. A visual hallucination:
Visual hallucinations involve seeing things that are not present. The client's statement does not describe a visual experience but rather a false belief about bodily sensations, indicating a somatic delusion.

A. Aspartate aminotransferase 20 units/L B. Platelets 250.000/mm3 C. Sodium 140 mEq/L D. Fasting glucose 175 mg/dL

Correct Answer is D

Explanation

A. Aspartate aminotransferase 20 units/L:
This result indicates the level of an enzyme in the blood. A value of 20 units/L is within the normal range (usually 10-40 units/L). Aspartate aminotransferase (AST) is an enzyme found in the liver, heart, muscles, and other tissues. Elevated levels might indicate liver damage, but 20 units/L is a normal value.

B. Platelets 250,000/mm3:
Platelets are components of blood that help with clotting. A value of 250,000/mm3 is within the normal range (normal range is typically 150,000 to 450,000/mm3). Normal platelet levels are crucial for preventing excessive bleeding or clotting.

C. Sodium 140 mEq/L:
Sodium is an electrolyte essential for maintaining the body's water balance and nerve function. A level of 140 mEq/L falls within the normal range (typically 135-145 mEq/L). Proper sodium levels are important for overall body functioning.

D. Fasting glucose 175 mg/dL:
This indicates the concentration of glucose (sugar) in the blood after a period of fasting. A level of 175 mg/dL is elevated. Fasting glucose levels above 125 mg/dL may suggest diabetes or prediabetes. Elevated glucose levels are a cause for concern as they indicate poor blood sugar regulation, which can lead to various health complications, including diabetes.

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

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