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 C

Explanation

A. Naltrexone:
Naltrexone is an opioid receptor antagonist. It blocks the effects of opioids and alcohol in the brain. It's often used as part of a long-term treatment plan to prevent relapse in individuals who have already stopped drinking and are trying to maintain sobriety. Naltrexone does not directly manage acute alcohol withdrawal symptoms. Instead, it helps individuals reduce or quit drinking over the long term by reducing the pleasure associated with alcohol consumption.

B. Disulfiram:
Disulfiram is an aversion therapy medication used as a deterrent to drinking. When someone taking disulfiram consumes alcohol, it causes unpleasant physical reactions, such as nausea, flushing, and palpitations. This discourages individuals from drinking while they are on the medication. Disulfiram is not used to manage acute withdrawal symptoms but rather serves as a deterrent to drinking for individuals who are trying to maintain sobriety.

C. Lorazepam:
Lorazepam is a benzodiazepine medication that acts as a central nervous system depressant. It is commonly used to manage acute alcohol withdrawal symptoms. Benzodiazepines like lorazepam help to reduce anxiety, agitation, and the risk of seizures associated with alcohol withdrawal. They are typically used in a controlled manner to provide relief during the acute phase of withdrawal.

D. Acamprosate:
Acamprosate is used in the maintenance phase of alcohol use disorder treatment. It helps individuals maintain abstinence by stabilizing the chemical imbalances in the brain that occur after prolonged alcohol use. Acamprosate is not used for acute withdrawal management but is instead prescribed to support individuals who have already stopped drinking and are trying to avoid relapse over the long term.

A. "Why did you feel like giving away your belongings?" B. "You should find a support group to attend." C. "Everyone feels a little down sometimes." D. "Can you tell me how you have been feeling lately?"

Correct Answer is D

Explanation

A. "Why did you feel like giving away your belongings?"
This response is empathetic and invites the client to explore their feelings and motivations. It shows understanding and can help the nurse comprehend the client's emotional state better.

B. "You should find a support group to attend."
This response suggests a proactive step to seek support, which can be helpful. However, it might be premature in this context as the nurse hasn't fully assessed the client's situation yet. It's important to understand the client's feelings and circumstances before recommending specific interventions.

C. "Everyone feels a little down sometimes."
This response minimizes the client's feelings and can be invalidating. It doesn't acknowledge the seriousness of the client's statement, which might discourage them from opening up further.

D. "Can you tell me how you have been feeling lately?"
As previously explained, this response is empathetic and open-ended, encouraging the client to share their emotions and thoughts. It's a good starting point for a therapeutic conversation, allowing the nurse to assess the client's current mental state.

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 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?

Correct Answer is C

Explanation

A nurse is caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is preparing to meet with a client who was recently admitted to an outpatient mental health facility. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship?

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency?

A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

A nurse in a community mental health clinic is assessing a client who began taking lithium carbonate 5 days ago. The client reports fine hand tremors and has a current lithium level of 1.2 mEq/L. Which of the following actions should the nurse take?