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 D

Explanation

A. "My partner and I recently had our fourth child."
Having a strong support system, such as a partner and family, especially during significant life events like the birth of a child, can be a protective factor against suicide. Supportive relationships are important for mental well-being.

B. "My family has a history of suicide."
A family history of suicide is a risk factor, not a protective factor. It indicates a higher risk for suicidal thoughts or behaviors.

C. “I have Crohn's disease, but it's well-controlled."
Having a chronic illness, even if well-controlled, can be a stressor, potentially increasing the risk of suicidal thoughts. It's not a protective factor.

D. “I just received my license to practice medicine."
Achieving a significant milestone, such as getting a medical license, can enhance self-esteem, provide a sense of purpose, and increase social support, making it a protective factor against suicide.

A. Request a prescription for varenicline from the client's provider. B. Initiate facility procedures for emergency commitment. C. Inform the client about policies for dispensing methadone. D. Assess the client using the CAGE questionnaire.

Correct Answer is C

Explanation

A. Request a prescription for varenicline from the client's provider.
Varenicline is used to help people quit smoking and is not indicated for the treatment of opioid use disorder.

B. Initiate facility procedures for emergency commitment.
Emergency commitment typically involves legal procedures and should only be pursued if the client poses an immediate danger to themselves or others. It is not the appropriate action in this scenario without further information indicating such a need.

C. Inform the client about policies for dispensing methadone.
Methadone is a medication used to help people reduce or quit their use of heroin or other opiates. Methadone is dispensed under strict regulations and guidelines due to its potential for misuse. The nurse should inform the client about the policies and procedures related to the dispensing of methadone, ensuring the client understands the rules and requirements associated with its use.

D. Assess the client using the CAGE questionnaire.
The CAGE questionnaire is a tool used to screen for alcohol use disorder, not opioid use disorder. While it's essential to assess the client comprehensively, using appropriate tools, in this case, informing the client about methadone dispensing policies is the most relevant action.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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