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 ["2"]
Explanation
Ordered: Lithium 300 mg
Available: Lithium 150 mg/cap
Formula:
Capsules=Dose ordered /Dose available
Capsules= 300 mg150 mg
= 2 caps
Correct Answer is D
Explanation
A. Place the client in a private room: While privacy can be helpful, it is not the priority intervention in alcohol withdrawal care.
B. Pad the side rails of the bed with towels: This is a safety measure to prevent injury during seizures but should follow the assessment of disorientation.
C. Accompany the client when ambulating: Fall prevention is important, but assessing the client’s level of disorientation takes precedence.
D. Determine the client's level of disorientation: The first step in care is assessing the client's mental status and level of disorientation to identify immediate needs and risks.
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