A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Constipation

Dry skin

Hypotension

Urinary retention

Answer and Explanation

The Correct Answer is C

Choice A reason: Constipation isn’t a primary effect of disulfiram-alcohol reaction, which causes acetaldehyde buildup, triggering vasodilation and nausea, not gut motility issues. Scientifically, this reaction targets cardiovascular and systemic responses, lacking evidence for significant gastrointestinal stasis as a monitored outcome in this scenario.

Choice B reason: Dry skin isn’t linked to disulfiram-alcohol interaction, which induces flushing and sweating from acetaldehyde toxicity, not dehydration. Scientifically, the reaction affects vascular and autonomic systems, producing moist, not dry, skin responses, making this an unrelated finding for monitoring here.

Choice C reason: Hypotension occurs in disulfiram-alcohol reaction as acetaldehyde dilates vessels, dropping blood pressure. This cardiovascular effect, alongside tachycardia, is a key sign to monitor, aligning with scientific understanding of the drug’s inhibition of aldehyde dehydrogenase, causing systemic distress.

Choice D reason: Urinary retention isn’t a typical disulfiram-alcohol effect; the reaction focuses on vasodilation, nausea, and hypotension from acetaldehyde. Scientifically, autonomic overstimulation may occur, but bladder dysfunction isn’t a primary outcome, making this less critical to monitor than cardiovascular collapse.

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Correct Answer is C

Explanation

Choice A reason: Taping to the cheek risks skin injury and tube displacement in kids. Abdominal securing is safer for gastrostomy stability and comfort.

Choice B reason: Extension tubes are for feeding, not routine site care. Attaching one now is premature, unrelated to maintaining the site itself.

Choice C reason: Securing to the abdomen prevents pulling or dislodgement of the gastrostomy tube. It’s a standard care step, ensuring stability and safety.

Choice D reason: Lubricant isn’t needed for site care; it may irritate skin. Clean, dry maintenance is preferred, making this an incorrect action.

A. Impetigo contagiosa B. Neisseria gonorrhoeae C. Human papillomavirus D. Sarcoptes scabiei

Correct Answer is B

Explanation

Choice A reason: Impetigo is contagious but not typically reportable unless outbreak-related. It’s a local bacterial skin infection, lacking mandatory public health notification status.

Choice B reason: Neisseria gonorrhoeae, causing gonorrhea, is a reportable STI per CDC guidelines. Reporting tracks prevalence and prevents spread, a legal nursing duty.

Choice C reason: Human papillomavirus isn’t reportable; it’s common and vaccine-preventable. Public health focuses on trends, not individual cases, unlike gonorrhea’s urgency.

Choice D reason: Sarcoptes scabiei (scabies) requires outbreak reporting, not routine cases. It’s less systematically tracked than gonorrhea, a priority STI for notification.

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A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Nursing Test Bank

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