A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?
Support the client's coping skills.
Prevent the client from harming herself or others.
Identify the use of defense mechanisms.
Develop goals for treatment.
The Correct Answer is B
A. Support the client’s coping skills. While important, safety takes precedence in the acute phase.
B. Prevent the client from harming herself or others. Alcohol withdrawal can lead to agitation, hallucinations, or seizures, making safety the nurse's priority.
C. Identify the use of defense mechanisms. This is part of long-term treatment, not immediate care.
D. Develop goals for treatment. Goal-setting is essential for long-term management but is not the priority during acute withdrawal.
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Related Questions
Correct Answer is D
Explanation
A. They do not care that they lost their job and their partner: This statement reflects apathy but does not define addiction.
B. They filed for bankruptcy because of their debts and job loss: This is a consequence of their addiction, not a defining characteristic.
C. They are depressed over their current life situation: Depression may coexist with addiction but is not a defining characteristic.
D. They compulsively act on the urge to continue internet gaming and gambling even though they suffered negative consequences: The hallmark of addiction is the compulsive engagement in the behavior despite adverse outcomes.
Correct Answer is D
Explanation
A. "I will send you a note in a few weeks.": This response is inappropriate and could blur professional boundaries in the therapeutic nurse-client relationship.
B. "I know you will do well living out in the community.": While supportive, this response assumes the client's future success without addressing their immediate feelings or concerns.
C. "Aren't you excited about being discharged today?": This response is leading and may not reflect the client’s true feelings.
D. "How do you feel about being discharged?": This open-ended question encourages the client to express their emotions and concerns about the transition, which is appropriate in the termination phase of the therapeutic relationship.
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