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.

Answer and Explanation

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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Correct Answer is B

Explanation

Increasing feelings of anger are a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.

Choice A is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.

Choice C is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.

Choice D is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.

A. Encourage verbalization of feelings. B. Provide an activity for diversion. C. Remain with the client. D. Have the client identify two coping skills.

Correct Answer is C

Explanation

If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.

Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

Correct Answer is B

Explanation

A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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