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 D

Explanation

Choice A reason: Voice alteration isn’t linked to ECT; it affects brain function, not vocal cords. Post-procedure, neurological effects dominate, not laryngeal changes.

Choice B reason: Neck pain may occur from positioning, but it’s not a primary ECT reaction. Muscle relaxants minimize strain, making this less common.

Choice C reason: Scalp tingling could stem from electrodes, but it’s rare and minor. ECT’s electrical impact targets memory and mood, not sensory nerves.

Choice D reason: Temporary memory loss is a well-documented ECT side effect, from disrupted hippocampal function. It’s expected, often resolving, and key to inform clients.

A. Release the client’s restraints every 4 hr. B. Check the client’s status every hour. C. Obtain written consent by the client for the placement of the restraints. D. Document the client’s behavior leading to the initiation of the restraints.

Correct Answer is D

Explanation

Choice A reason: Releasing restraints every 4 hours lacks context; policy requires 2-hour checks with release if safe. Scientifically, this risks neglect, as frequent assessment ensures circulation and safety, making it less precise than behavior documentation.

Choice B reason: Hourly checks are good but not the action specified; 15-minute intervals are standard for restraints. Scientifically, this underestimates risk monitoring needs, as behavior justification is a legal and clinical priority over timing alone.

Choice C reason: Client consent isn’t required for restraints in emergencies; provider orders suffice. Scientifically, imminent harm overrides autonomy, and consent isn’t feasible mid-crisis, making this impractical and misaligned with restraint protocols.

Choice D reason: Documenting behavior justifies restraints, ensuring legal and ethical use for safety. Scientifically, this aligns with standards, as specific actions (e.g., aggression) validate intervention, providing a clinical basis critical for care continuity and review.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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