A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?
Identify the use of defense mechanisms.
Prevent the client from harming herself or others.
Support the client's coping skills.
The Correct Answer is B
Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.
Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.
Choice C, supporting the client's coping skills, is not a priority intervention.
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Related Questions
Correct Answer is B
Explanation
Allow the client to exercise once per day for a set amount of time. It is important to set limits and boundaries for a client with anorexia nervosa to ensure their safety, but also to respect their autonomy.
Reminding the client of weight loss consequences (choice A) can be counterproductive, asking why they exercise frequently (choice C) is important, but not sufficient without setting boundaries, and allowing the client to exercise as long as they eat 50% of their meals (choice D) can be dangerous.
Correct Answer is A
Explanation
Moderate. According to the Mayo Clinic moderate anxiety is characterized by symptoms such as loud and rapid speech, difficulty concentrating, restlessness, and increased worry. The client's behavior matches these symptoms, indicating that they are experiencing moderate anxiety.
Choice B. Panic is incorrect because panic is a severe form of anxiety that involves symptoms such as chest pain, shortness of breath, trembling, and a sense of impending doom. The client does not exhibit these symptoms.
Choice C. Severe is incorrect because severe anxiety is marked by symptoms such as irrational fear, detachment from reality, hallucinations, and loss of control¹². The client does not show these symptoms.
Choice D. Mild is incorrect because mild anxiety is associated with symptoms such as nervousness, increased alertness, and slight discomfort¹². The client's symptoms are more intense than mild anxiety.
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