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 B

Explanation

Choice A reason: Bathing under running water risks temperature instability and drowning in newborns. This is unsafe, showing a lack of proper care understanding.

Choice B reason: Washing the face with a warm, wet washcloth without soap protects delicate skin, avoiding irritation. This aligns with newborn hygiene best practices.

Choice C reason: Moist towelettes often contain chemicals, unsuitable for newborn scalps. Warm water and cloth are gentler, so this reflects misunderstanding of care.

Choice D reason: Daily baths dry out newborn skin, increasing irritation risk. Spot cleaning is advised, making this an incorrect application of hygiene teaching.

A. Offer the client several choices at mealtimes. B. Alternate daily caregivers. C. Avoid discussing the client’s fears. D. Remind the client of the day and time often.

Correct Answer is D

Explanation

Choice A reason: Offering multiple choices overwhelms a delirious client, whose impaired cognition struggles with decisions. Scientifically, delirium reduces attention and processing, so simplifying options aids comfort, making this counterproductive to managing their acute confusional state effectively.

Choice B reason: Alternating caregivers disrupts continuity, worsening disorientation in delirium. Consistent faces aid recognition, reducing anxiety. Scientifically, familiarity stabilizes perception in acute confusion, making this detrimental to the client’s need for a predictable environment during recovery.

Choice C reason: Avoiding fears ignores emotional distress, potentially increasing agitation in delirium. Addressing concerns gently can calm. Scientifically, unaddressed anxiety exacerbates confusion, so this neglects a holistic approach needed for managing the client’s psychological state effectively.

Choice D reason: Reminding of day and time reorients the client, countering delirium’s disorientation. Frequent cues anchor perception, aiding recovery. Scientifically, this aligns with evidence-based care, as repeated orientation reduces confusion’s impact, supporting cognitive stabilization in acute delirium management.

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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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