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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Recent head injury:
A recent head injury is a potential concern when considering the prescription of bupropion. Bupropion can lower the seizure threshold, and head injuries might increase the risk of seizures. Therefore, it's important to report a recent head injury to the healthcare provider to assess the client's suitability for bupropion.
B. Hepatitis B infection:
Hepatitis B infection is not a contraindication for bupropion. However, the healthcare provider should be aware of the client's full medical history, including hepatitis B infection, to ensure appropriate monitoring and management, especially if the client is taking other medications or has liver function concerns.
C. Hypothyroidism:
Hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormones, is not a contraindication for bupropion. However, the healthcare provider should be aware of this condition to monitor the client appropriately, as thyroid function can influence the metabolism of medications.
D. Knee arthroplasty 1 month ago:
Knee arthroplasty (knee replacement surgery) performed one month ago is not a direct contraindication for bupropion use. However, the provider should be informed of recent surgeries or procedures, especially if the client is taking medications or undergoing physical therapy, to ensure there are no potential drug interactions or complications related to the recent surgery. It's essential to monitor for signs of infection or other complications post-surgery.
Correct Answer is C
Explanation
A. Long-term isolation: Long-term isolation, or social isolation, can lead to feelings of loneliness and depression. While prolonged isolation can contribute to mental health issues, it is not a direct risk factor for violent behavior. People who are socially isolated might suffer from emotional distress, but it doesn't necessarily make them violent.
B. Dysthymic disorder: Dysthymic disorder, also known as persistent depressive disorder, is a type of chronic depression. While individuals with dysthymic disorder may experience low moods and a lack of interest in activities, it doesn't inherently make them prone to violence. Depression is more likely to cause self-directed harm (such as self-harm or suicide) rather than violent behavior towards others.
C. Alcohol intoxication: Alcohol is a substance that impairs judgment and reduces inhibitions. When a person is intoxicated, they may act aggressively or violently, even in situations where they wouldn't normally do so. Alcohol intoxication can lead to a loss of control, impaired decision-making, and aggressive behavior, making it a significant risk factor for violent actions.
D. Schizoid personality disorder: Schizoid personality disorder is characterized by a lack of interest in social relationships, emotional coldness, and detachment. While individuals with this disorder may prefer to be alone and avoid social interactions, they are not necessarily prone to violent behavior. Schizoid personality disorder primarily affects social functioning rather than predisposing someone to violence.
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