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
The nurse should recommend establishing a reward system for positive behavior when contributing to the plan of care for a child with an autism spectrum disorder. Reward systems can be particularly effective for children with autism spectrum disorder, as they respond well to structured routines and consistency.
Choice A, assuring that the child has a large variety of caregivers, is not recommended, as children with autism spectrum disorder can be particularly sensitive to changes in routine and caregivers. Providing a flexible schedule to adjust to the child's interests,
choice C may be appropriate in some cases, but a structured routine can be even more beneficial. Allowing for imaginative play with peers without supervision, choice D, may not be safe or effective in all situations. It is important for the nurse to work with the child, their family, and other healthcare professionals to develop an individualized plan of care that meets the child's specific needs and goals.
Correct Answer is A
Explanation
Answer: A. "It sounds like you're having a difficult time."
Rationale:
A) "It sounds like you're having a difficult time":
This response is empathetic and acknowledges the client's distress. By validating the client's feelings, the nurse provides support and opens the door for further discussion about their anxiety and related symptoms. This approach can help the client feel understood and encourage them to share more about their experience.
B) "Have you talked to your provider about this yet?":
While it is important for the client to communicate their symptoms to their provider, this response might come across as dismissive of the client's immediate emotional state. It could be more supportive to first acknowledge the client's current experience before suggesting further actions.
C) "Everyone has trouble sleeping at times":
This response may minimize the client's concerns and fail to address their specific experience. It can come off as invalidating by suggesting that their situation is normal and not warranting further exploration or support.
D) "Why do you think you are so anxious?":
Asking why the client feels anxious might be perceived as interrogative rather than supportive. This approach could put pressure on the client to explain their feelings, which might not be productive if they are struggling to articulate their emotions or causes of anxiety.
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