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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3"]
Explanation
Ordered: Fluoxetine 30 mg PO daily
Available: Fluoxetine 10 mg/tablet
Formula: Tablet s=Dose ordered /Dose available
Tablets= 30 mg10 mg
=3 tablets
Correct Answer is B
Explanation
A. "Alcohol tolerance causes the client to have an increased effect when taking opiates." Alcohol tolerance is specific to alcohol and does not directly increase the effect of opiates. However, cross-tolerance with other sedatives (e.g., benzodiazepines) may occur.
B. "Alcohol tolerance can result in a decreased physical response to alcohol." Alcohol tolerance develops as the body adapts to frequent alcohol use, requiring higher amounts to achieve the same effects.
C. "A client who has alcohol tolerance develops physical changes when they haven't recently ingested alcohol." This describes alcohol dependence, not tolerance. Physical changes, such as withdrawal symptoms, occur with dependence.
D. "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal." Tolerance develops over time with frequent alcohol use. Withdrawal symptoms are the result of dependence, not tolerance.
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